If it don’t fit, don’t force it

Templates in primary care medicine suck.

Why? The problem with templates in primary care medicine is they focus on getting a specific list of questions answered for something like ear pain or back pain. They miss the weird stuff. They miss the outliers.

I hated the templates when we got our first electronic record in the early 2000s. The doctors who liked computers spent a year picking the system. Then they trained all the clinics for one week and we all went live. One of the biggest problems was that they liked computers and talked the language. We didn’t. We quit asking questions within a week, because when we asked a question it 1. Was a user problem and 2. They treated us like we were stupid and 3. They answered in Geek, which we did not understand.

We quit asking questions. The nurses and I all filed for workman’s comp because our shoulders locked up. Our shoulders hurt. We figured out how to get the stupid thing to work. Every doctor and nurse and PAC and nurse practitioner worked to figure it out on our own.

Two years later, they set up some standards for use. We resisted again, because they gave us orders in Geek and anyhow, we had no respect for them and we didn’t care. Change what we were doing? After no support for two years? Good luck!

It took me two years and three months to get the system to write what I considered a good clinic note. I had contacted an outside specialist three months in and asked how our notes were.

“You want me to be honest?” he said.


“They suck. They are useless.”

“That’s what I thought.” I went on fighting the system and hating it. I won, eventually. Parts of my note continued to suck, but I figured out how to work around the stupid templates and put in some REAL information.

Now wait, you say, is the template totally useless?

In some situations, like emergency rooms, it may be very useful. It helps keep a harried ER team with four people from a car wreck from missing something. And if you are an ENT, otolaryngologist, you do see a lot of ear and mouth and throat things, so templates may help. But I think they are terrible for primary care.

They are good for billing, though. If you have all the boxes checked, the insurance company pays, and you can move on to the next victim. The insurance companies pay more if you see more people in a day. That is why our administration said, “See people for one thing per visit.”

However, that is not ethical. Say it is a 70 year old diabetic with atrial fibrillation on coumadin with a bladder infection. You cannot just say bladder infection and slap them on sulfa. For one thing sulfa screws up the coumadin and puts them at risk for bleeding. For a second, diabetes can affect kidney function and so can age and you have to adjust antibiotic dose for lower kidney function. For a third, if their glucose levels are out of control, the infection may not be controlled by an antibiotic. It’s not one thing. And the average patient has 4 chronic disorders in a study way back in the early 2000s. That means some people have none, some people have eight or more and most people have 3-5. Hypertension, diabetes, toe fungus, chronic shoulder pain, heart disease, the list goes on and on.

In any visit, I am alert for the things the DON’T fit. One time I am doing a new patient visit for back pain and note that she is hoarse. I bug her about the hoarseness. She admits it is continuous and has been there for two months. I do two referrals, because continuous hoarseness can be laryngeal cancer.

When she returns, she thanks me. She has vocal cord polyps, not cancer, but needs laser surgery. “You didn’t have to do that but you did.” she says. And do I feel good about not ignoring it? The visit went over time, but I’d rather go over time than miss laryngeal cancer, right?

We were taught to let the patient talk. Open ended questions. They’ve done studies that doctors cut people off from telling their stories very very quickly. If you let people talk, sometimes they say something that doesn’t fit the template, and we have to pay attention. Sometimes a comment or a couple comments are the clue, the key, the thing that doesn’t fit. Don’t force it into the template. Pay attention instead.


The very serious group of people is a county medical meeting, 2014.

4 thoughts on “If it don’t fit, don’t force it

  1. Ahhh…there I was at 52 with bone-on-bone osteoarthritis in my hip but my Primary Care physician based his diagnosis — I believe — on a template. 52 year olds don’t have the hips of an 80 year old (he more or less said). Didn’t X-ray my hip. X-rayed my back. Scoliosis. Physical therapy for Piriformis Syndrome (made the hip worse). Two years later, after yelling at me for “not getting better” he X-rayed the hip. I had 6 months or my window of opportunity for hip resurfacing would close. He yelled at me for wanting that instead of a replacement. He had no credibility with me and I’d gone to a specialist with my X-rays. I have another nightmare experience, but never mind that. At this point in my life, when I go to the doc, I become tachycardic and the PA and I have to sit and chat til my BP goes down. I’m seriously terrified.

    • drkottaway says:

      Doctor PTSD: I have it too.

      • I’m sorry you have it — but I’m glad it’s a real thing and I’m not just a neurotic freak. My PA even asked me, “Do Heidi and I scare you?” I felt so bad. I said, “No. It’s stuff from the past.” They had me track my BP at home for six months to make sure I wasn’t on the verge of death… When I showed up with an Excel spreadsheet and graphs they just cracked up.

  2. Aah, templates! We had an optional template for our handwritten notes, which ran about a page. When we switched to EMR, the template and note kept getting longer. The thought was, if you could easily add it , why not? (Without actually answering that question.) My colleagues’ notes sometimes ran to 8 pages. (I knew how to cut things, so mine were shorter.) Resident notes were the worst, since they copied and pasted everything. Not only long and full of irrelevant detail, but outdated – stupidly so.

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