“I am an unwilling, unwitting part of the Industrial Medical-Letter-Writing Complex, which pulls every clinician, every health worker, and every patient into its roiling, gasping vortex. It is the ever-hungry ghost. With a bottomless stomach and inky black eyes, it eats good intentions for breakfast, inhales reams of paper for lunch, and takes your sanity and humanity for its dinner. It laughs at boundaries, derides common sense. It matters not how long ago it was when I last saw the patient. It matters not if I have ever met them before. It matters not who made the form, or if it is a good idea, or how many times the form asks to write down a patient’s name, birth date, and Social Security number. The form is here. The form lords over all who stand in its path, and it needs completion by end of day TODAY. As a primary care physician, the Industrial Medical-Letter-Writing Complex is the one who knocks.
A pet, a bathroom, food to eat. The patient in front of me seems deserving because all people seem deserving of those things. I also do not want to live in the epicenter of San Francisco’s fentanyl trade or share a kitchen or look at a brick wall. I want to say yes, watch the patient leave uplifted, a win notched on their belt, emotional support animal by their side. Yes to you. And to you. Yes to all of these. It seems the decent, reasonable thing.
Or in fact will writing too many of these create a bottleneck of need where patients who truly need things are not able to access those things amid the glut of not-so-needed medical necessity letters? But truly, what is truly? To know who should get these precious resources would mean you must know how many of said resources there are, how many people request them, and then what the collective diagnoses are of the pool of requestors. And yet I know neither the numerator nor the denominator of this math problem. All I know is that a patient in front of me would like to be a part of it.
Because the doctor said so. They need someone to allot. To apportion. I am adult supervision, the arbiter of big and small. The can got kicked down the road until it landed in my office.
If only spilled ink led to apartments outside of the Tenderloin, or anywhere, for that matter, for anyone to move into. If only signed letterhead could create 8000 housing units for San Francisco’s 8000 homeless.
I hope that letter helps. That letter is either the most powerful, life-changing thing I have done all day, or it is the most ineffectual. And somehow, inexplicably, confoundingly, I can’t seem to figure out which.”
Full editorial, K Taylor, JAMA, 2025.4.10