Some patients come to see their doctor for a check-up. Some for help with a medical mystery. And some just need a letter.
In her striking JAMA editorial, Dr. Kathryn Taylor captures the absurdity and emotional dissonance of what she calls the "Industrial Medical-Letter-Writing Complex," a vortex of bureaucratic form-filling that sucks in good intentions and spits out soul-crushed clinicians. Her essay is a must-read for anyone trying to understand why so many physicians seem frustrated, disillusioned, or perpetually 30 minutes behind.
Her examples will ring familiar for anyone who's spent time in a primary care clinic: letters for housing accommodations, emotional support animals, work clearances, or proof of illness that only exists in symptoms, not signs. She wryly notes the paradoxes: sometimes patients want to appear maximally ill (for disability benefits); other times, maximally healthy (for job applications or driver’s licenses). All need a signature. None really need a doctor.
Let’s be clear: many documentation requests are not frivolous. Some even change lives. But here’s the uncomfortable truth: far too many are a waste of a highly trained professional’s time and clinical judgment. Physicians are being turned into bureaucratic bouncers: guarding access to services they neither control nor fully understand, with the power to say "yes" or "no" based not on diagnostic certainty, but on narrative plausibility. Did the patient look like they needed the accommodation? Did they seem sincere?
I've had patients come in simply for a school or camp form, despite already having had a recent physical exam. I've been asked to provide referrals to specialists that patients have been seeing independently for years, a bit of performative medicine to satisfy a payer rule. I've written return-to-school notes for ailments that resolved before the appointment was scheduled. These aren’t just annoyances; they’re examples of a larger problem: we are clogging the healthcare system with paperwork masquerading as care.
Why does this happen? Because someone needs to "say so." Want to keep your food by your shelter bed? The doctor has to say so. Want a first-floor apartment because of your COPD? The doctor has to say so. Need to prove you're healthy enough to drive or work or live independently? You guessed it.
Physicians, who are trained to diagnose, treat, and heal, are now also expected to adjudicate social benefits, housing needs, transportation eligibility, and workplace accommodations. We are playing roles more akin to judges and notaries than medical experts. And because many of these decisions aren’t guided by objective criteria, the physician becomes the bottleneck, the scapegoat, or the savior, depending on the outcome.
There’s a particular cruelty here: if you want your doctor to write that you are sick, you often get a sympathetic ear. If you want your doctor to write that you are well, you better hope you didn’t miss your last wellness visit. Either way, the burden falls on a clinician who may not know you well, who may lack access to the relevant records, and who certainly didn’t go into medicine to serve as a proxy gatekeeper for housing authorities or DMV clerks. Too harsh?
Dr. Taylor's piece ends with the tension that haunts many of us: "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."
This ambiguity is corrosive. It erodes trust, inflames burnout, and commodifies the clinical encounter. When visits become transactional ("Hi doc, I just need a note"), we lose the relational core of medicine. Patients become petitioners. Doctors become scribes of bureaucratic intent.
To be fair, this is hardly ever the patient’s fault. The system is designed to offload decision-making to clinicians, not because we’re best equipped to make these calls, but because no one else wants to. It’s convenient to have a doctor play Solomon. But when everyone expects you to be the gatekeeper, the gates get clogged.
So what’s the way out?
First, we need to right-size the scope of medical documentation. If a form doesn’t require clinical expertise, it shouldn’t require a clinician’s signature. Let school nurses, pharmacists, or social workers handle the low-stakes paperwork that currently eats up valuable exam slots.
Second, we must standardize and simplify common forms. Every state, agency, and employer seems to have their own slightly different version of the same medical clearance or disability verification form. It’s death by a thousand paper cuts.
Third, we need to stop pretending that physicians can (or should) validate every aspect of a person’s life circumstances. Doctors are not housing specialists, transit evaluators, or legal referees. We can support patients, but we should not be the sole arbiters of who gets what based on vague documentation demands.
And finally, healthcare leaders need to acknowledge this burden and build operational buffers. Create dedicated (and hopefully virtual) "form clinics" staffed by nurses or PAs. Provide protected admin time for physicians. Integrate EHR tools that auto-fill common documents and flag non-clinical requests for redirection.
The Industrial Medical-Letter-Writing Complex will not implode on its own. It will continue expanding until we say: enough. Until we re-center care on relationships, not red tape. Until then, physicians will be in their offices, stethoscope in one hand, pen in the other, trying to decide whether the emotional support hedgehog qualifies for an exemption to the no-pets policy.
Because someone has to say so.