The tyranny of the inbox: What it’s like to be a PCP with OCD

Like so many health care workers, I have seriously considered giving up my clinical practice multiple times — even more since the onset of the pandemic. For me, wanting to bail out of my job as a primary care physician has nothing to do with the risk of contracting Covid-19 or any other communicable disease. The real reason is best summarized by the unimaginably annoying Lamb Chop’s Play-Along Song.

This is the song that doesn’t end.
Yes it goes on and on, my friend.

The perpetual flood of messages from patients, test results, and triplicate notifications from just about everything in the electronic medical record (EMR) overloads my hyper-detail-oriented mind, just like the song did when I was a child. My symptoms of obsessive-compulsive disorder (OCD) were starting to appear around the time I first heard it.

During childhood, my bedtime compulsions began when the lights went out: In a highly ritualized manner, I’d make sure no monsters were lurking in my room by running my hands between all the posts of the bed frame, opening and closing the closet, then checking under the bed. Before ice hockey practice began, I’d plead with my parents, and sometimes throw tantrums, so they would tie my skates and align my shin pads just right. Sometimes, bless their hearts, they’d do that a dozen times before I was satisfied.

During medical school, hypochondriasis and disease obsessions ruled the day. In my second year, my worries about sexually transmitted infections sent me into a tailspin. Fortunately, I saw an astute psychiatrist who diagnosed OCD, where others had labelled me as anxious and needing talk therapy. With the help of medications and cognitive behavior therapy, I came out of the depression and learned to recognize and cope with my obsessions before they got beyond my control. I survived four years of residency without a crisis.

None of my training prepared me to become a primary care physician in the age of the electronic medical record.

Every workday, without fail, I walk into a clinic full of patients, and I can’t wait to start seeing them. But my inbox is bearing a tidal wave of messages from patients, results to follow up, and almost entirely useless notifications from the EMR. The always-overflowing inbox provokes a sense of internal discomfort, much like my skate laces and misaligned shin pads used to do. That sense of discomfort is what compels me to bring my inbox to zero several times a day, and always before I leave work each day.

As I see patients, my attention focused on the person in front of me, my inbox swells, continually betraying me. For someone living with OCD, no one could have devised a more effective means of torture than the steadily refilling inbox. It gnaws at the joy and sense of privilege it is to be a primary care physician.

Clinicians don’t have to be living with OCD to feel the way I do. My colleagues constantly bemoan inbox fatigue and EMR notification overload. On a recent Saturday, I picked up an extra urgent care shift and, when I arrived, was surprised to find a primary care colleague working at his office computer. “If I don’t clean out my inbox now, I’ll never catch up during the week,” he lamented.

Despite the obvious need for a system that’s better than paper charting, the advent of the electronic medical record has led to records so filled with noise it’s hard to decipher the signal. Notifications from the EMR were designed to prevent clinicians from overlooking things, but they mainly create more work with rare benefit and a real harm — click fatigue — for which clinicians are given no extra time or pay. It’s one reason why my colleagues are logging unpaid overtime on the weekends to keep their heads above water.

And now that the 21st Century Cures Act mandates that patients get access to their test results the nanosecond they’re available, nearly every test a clinician orders creates an email notification, creating a new inbox influx. When I see patients in my complex primary care clinic, I can order as many as 15 lab tests per visit. Multiply that by eight patients per half day session, and you can see the tsunami forming.

Physicians once used to review the collection of lab results with a patient at a future visit. Now that they’re available in real time, patients want real-time answers, generating more messages, not to mention more anxiety anytime a lab value is marginally outside the reference range.

Several institutions, including the one I work in, have recognized the burden email messages and electronic medical record notifications are placing on beleaguered clinicians. Some now charge patients for these electronic visits, which is exactly what they are, though this may have only a modest effect on the volume of emails. Others choose to truncate the length of messages patients send, but institutions vary in what they allow. A few have even started hiring physicians and other clinicians to provide inbox coverage for primary care providers while they’re out on vacation.

To preserve my sanity, I have stopped responding to messages from patients that require more than a one-line response from me, and instead ask my assistant to schedule them for visits. I take the same approach for abnormal laboratory and imaging results. That way, the time I spend seeing patients is just that, and I’m not trying to juggle my time between my inbox and my patients, even if that means I’m overbooked.

All these strategies fail to address a fundamental problem: Technology for tracking patients and their care has evolved, but systems for supporting clinicians have not. This has had the net effect of delegating too much responsibility to individual clinicians for everything. Burnout will remain high until administrators and clinicians learn to take a team-based approach to patient care that incorporates dedicated inbox management for primary care physicians, employ well-trained scribes as standard practice, demand that vendors of electronic medical record systems make their software user friendly, and improve care coordination to lift the burden from individual clinicians. They should be guiding patient care and medical decision-making, not micromanaging every detail of patient care while also serving as highly trained human fax machines.

Regarding my future in medicine, I am not convinced I can practice clinical medicine in America without reinforcing my maladaptive OCD tendencies, or flat out compromising the quality of care I deliver by ignoring inbox alerts. But it’s a risk I’ll take. I love the heart of medicine: meeting new people, getting to know my patients over years of visits, and using my understanding of science and medicine to help heal them when they are sick. So I’ve stuck it out. But how long can any of us last at this pace?

This song must end for the sake of all clinicians, not just those with OCD, and the people they care for. And it needs to happen soon, before more clinicians are lost in the war of attrition against the electronic medical record.

Russell Johnson is an internist, pediatrician, and HIV primary care specialist in Los Angeles who raises awareness about preventing HIV and sexually transmitted infections on TikTok.

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