A Bureaucratic Rebellion


Every residency class needs its symbolic rebel, an outsider who will risk it all in the fight against inane and superfluous paperwork. When your program is demanding redundant treatment plans, insisting on triplicate no-show notes, or reminding you to complete some tedious log, this resident is the kind of leader who will confront the administration with tough phrases, like “This form is ridiculous.”

Every residency class needs its symbolic rebel, an outsider who will risk it all in the fight against inane and superfluous paperwork. When your program is demanding redundant treatment plans, insisting on triplicate no-show notes, or reminding you to complete some tedious log, this resident is the kind of leader who will confront the administration with tough phrases, like “This form is ridiculous.”

As you can see, this is not a job for the average compliant milquetoast psychiatry resident.

But don’t look at me. For months, I’ve been trying to write an essay exposing the bureaucratic struggles that plague psychiatry residency. But it is hard enough to keep up with all the forms, certifications, documentations, evaluations, logs, renewals, and tutorials required by my job when I actually do them. Protesting is so time consuming it means I would never get around to my expos!

For a while earlier this week I thought I’d be able to work on the essay but instead I found myself glued to the Internet, completing a mandatory social media policy quiz that I’d been putting off. (Technically, it was not a “quiz,” but rather the more intimidating-sounding “module.”)

Once I completed the module, a “Certificate” appeared on my screen. Aglow with an unexpected pride, I printed the certificate and filed it with my life’s other treasured documents, under “C” for certificate, in between my birth record and my program’s death and dismemberment policy.

The module got me wondering-why did my program decide to roll out a social media policy just now? My guess is that this policy, like most policies, began with a scandal. New policies usually surface when the administration has something it doesn’t want us to know about.

For example, when I was in medical school, the local paper reported that a celebrity was coming to our town for some kind of treatment. The next day, we were deluged with HIPAA reminders. The reminders proved what the Channel 4 news truck parked in front of the hospital entrance could only hint at-the celebrity must have checked in! To our hospital!

So when I received an invitation to peruse my program’s new social media policy, I went straight to Facebook to find the trail of disgraceful postings by the responsible student or resident. After spending several hours in this manner, I had not found the guilty party. I did notice that it had gotten too late to work on the essay.

I also tried to work on it last week, but got distracted by a required online HIPPA training course. Actually, it was a HIPAA refresher course. This year’s crop of questions had some real stumpers, such as: “True or False: Protected health information must be protected.” To make things even more challenging, the Web site was revamped in the last year and is now exponentially harder to navigate. Luckily, I passed the course on my fifth or sixth try.

I would have worked on my essay after that, but my email inbox was besieged with alerts. The deadline to view an online lecture about the importance of sleep for residents was looming, and shockingly, I had not yet completed this required activity. It is more of a tutorial, really, than a lecture, meaning it utilizes the kind of invigorating English prose immortalized in supplemental indexes to quarterly actuarial bulletins published by insurance company committees.

I was carefully organizing these crucial alerts in a folder, so as to read them later, when I got locked out of my email! It appears I had neglected to respond to a password update requirement notification. In fact, I had failed to heed 15 of these announcements over the last 3 months.

Seven years into my medical training, I sometimes forget that my primary job consists of forms, logs, reports, modules, evaluations, verifications, password changes, and key deposits. Patients occasionally turn up, seemingly out of the blue, often just as I am beginning a crucial badge renewal form.

Should I be surprised that I am pulled in so many directions? It is common for residents to feel overburdened. At least, that’s what it says in the “Stress Management” pamphlet I received during orientation to residency.

The frustrations of medical training should hardly be news to readers of the Stress Management pamphlet, however. After all, the first thing that confronts medical school applicants is the Byzantine AMCAS system, where applicants must enter every college course ever taken and every grade received, one by one. (Note to applicants who may have whimsically registered for “Paper Mach: Beginner Fun” via the “Joy of Learning” summer mailer from the local community college and then neglected to withdraw when a fruit fly-sorting job at the lab came through-yes, this class and its unfortunate grade must be listed too.)

AMCAS then  calculates its own GPA using an equation devised by Albert Einstein. A little known fact about Einstein is that he wanted to go to medical school and become a geriatric psychiatrist, but after a valiant, failed effort to figure out AMCAS, he gave up and embraced his second choice, physics. As for me I’m pretty sure I spent more time entering information on my AMCAS application than I did taking some of those courses.

But do I feel defeated by all this bureaucracy? No! For I have a routine for dealing with it, a time-honored, self-perpetuating cycle of passive-aggressive procrastination that never fails to inspire me with a smug, self-righteous sense of superiority.

It goes like this: when I am told to complete some irritating task, first I do nothing until I receive a second reminder, if not a third, preferably from an exasperated authority figure. When my inbox starts to teeter on the precipice of unmanageability, that’s when I gear into action. I seethe and fume.

I don’t seethe and fume alone. With the help of Wikipedia, I recollect the moving words of famous writers of the past. The confessional poets are my favorites, because they complained a lot. For example, in For the Union Dead, Robert Lowell laments the “savage servility” of the modern masses. Most people erroneously believe that this poem is about some forgotten Civil War hero. However I am pretty sure it actually is about the legions of gullible psychiatry residents everywhere who complete all their forms, modules, evaluations, tutorials, notifications, and logs on time.

Next, I often will compose a letter to the president of the medical school emphasizing how time spent on paperwork detracts from patient care. If I am especially inspired, I might cite the Paperwork Reduction Act of 1980 (which really makes a point, as it takes up several pages).

I finish these missives with a flourishing click on “Save Draft.” Then I forget about the requirement until 6 weeks later, when I receive a message that mentions the possibility of suspension, often conveyed in the tone of voice used by collections agents. At this point, I just go ahead and do whatever it is they want.

But my ways are changing. Recently, our class received a reminder extolling us to get caught up on discharge summaries. Anyone who had to be “reminded” about getting caught up, it said, would be called to a remediation meeting with the hospital’s director of psychiatry.

I was puzzled that we seemed to be receiving a reminder warning us about a reminder, and wasn’t sure if receiving the reminder meant I was being reminded of something or not.

To be safe, I turned myself in and scheduled a remediation meeting with the director, where my burning questions about documentation-such as, “Why must we write in black ink?”-were answered. (The answer was enlighteningly simple: JCAHO. JCAHO makes all the rules. And here all this time I thought it was Halliburton.) Not only was the meeting very pleasant; the director thanked me for taking such an interest in documentation.

Since then, my fight against paperwork has been wavering. It is nicer to be thanked than to have the thankless, futile job of protester. And it leads to a lot fewer reminders.

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