The Tyranny of ‘Just Sign Here’

Sign here. And here. And here. And here.

How many times a day do you sign your name? Some days it feels like I scroll my signature across the page, on printed durable medical equipment prescriptions, at the bottom of a school or work health form, on multiple pages of home care orders, hundreds of times.

True, this is much better than the long-ago days when we had to handwrite our admission notes in the paper charts, the poor intern’s hand cramping as they finished their 10^th or 12^th admission note of the day. Many advances have been made since then, including the electronic medical record with all its bells and whistles, voice recognition software, and computerized order entry. No longer do we hear people complain about doctor’s handwriting, or get calls from the pharmacy asking whether that prescription was for Benadryl or Benazepril.

I can still remember the sound of one of my fellow interns signing admission orders in a patient’s chart. We worked together for the first few months on the inpatient wards, on paired rotations, and so distinctive and ingrained in my mind was the sound of his scratchy signature in the charts that I remember calling out from the nurse’s station one night after hearing that familiar sound, “Is that you, Alex?”

I also remember that when I was a teenager my parents forced me to take typing lessons, convinced that having the skill of touch typing would make me somehow more employable. In the back of my mind, I remember thinking, “I don’t want to have to do a job where I have to type.” Little did I know that so much of my time would be in front of a keyboard, clicking on boxes and typing out my history, physical, and assessment and plan.

But for all the paperwork that still exists in our lives, can we think of a better way to deal with this, get rid of the need for all this paper that floods our offices every day? How many times have we, as primary care doctors, had patients tell us, “My (insert type of specialist) doesn’t fill out forms; they told me that you have to do it”? True, it’s in our interest to make sure that our patients get the care they need. But why, when a patient is taken care of primarily by a subspecialist, do the forms come to us? Perhaps it’s just that we’re the only suckers willing to just do it.

I think the time has come for us to figure out a way to get this all done, to get our patients what they need, without this having to be busywork. Perhaps we can build into these fancy electronic medical records a place for all of the stuff currently on paper to live — the home care orders, the durable medical equipment, the school and work forms. Surely, we (or they?) must be smart enough to template this stuff, to automate this stuff, to make it available for everyone who has some input into it to add their two cents, and then route it off to the appropriate places?

For heaven’s sake, can’t we figure out how to electronically prescribe durable medical equipment? How come a doctor can prescribe a pound of morphine electronically, but I can’t send an electronic prescription for a shower chair to a durable medical equipment supplier?

Once I sent a prescription for a piece of durable medical equipment — I think it was a hospital bed — to a large vendor, printed from our electronic medical record and hand signed by me. The company sent it back, telling me that the regulations required that I handwrite the date on the prescription, and initial next to my signature. Wait a minute: the prescription already has the date on it, and why the heck am I initialing my signature? Do I then have to date my initials, and sign next to the extra handwritten date? Clearly, this was someone misunderstanding the rules. If not, then that is one wacko rule that needs to be changed.

Every day we get reams of paper from home care agencies, almost always marked “URGENT, 3^rd request, must reply within 24 hours”. Detailed therein are a long list of the patient’s medicines, activities of daily living and nursing activities they need help with, and then several pages that list the goals of their home care treatment. These often feel like things chosen from a huge menu, and never actually that well thought out or specifically tailored for the patient in question.

I love how they always say that these are verbal orders received from Dr. Pelzman, even though they never talked to me and I never talked to them. And even better is the place where they’ve electronically signed the form, but then they say that a doctor’s stamp or our electronic signature is not allowed. Wouldn’t it be better if we could all just agree on the care plan for a patient, and have this live somewhere in an electronic system that we all communicated back and forth with?

If we’re going to continue to improve the lives of those of us out here taking care of patients, we need to find more ways to alleviate the administrative burdens that always fall on us, that really don’t have that much to do with doctoring. And if we get one more call from an agency telling us that if we don’t sign this immediately and fax it back right now, then they’re going to turn the patient out on the streets, well, we might just have to call their bluff, and then call the New York Times.

Sign here if you’re with me.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.

Last Updated August 09, 2021