Why Do I Have to Make the Same Clinical Decision Twice?

A few weeks ago, I saw a patient with diabetes that had been drifting out of control. We talked through everything carefully. Her labs, her medications, what she could afford, what she could realistically manage day-to-day. We adjusted her treatment and landed on a plan that made sense.

It was a good visit. The kind where you feel like you’ve helped move things forward.

Then she came back — not because the plan didn’t work, but because it never really got started. The prescription hadn’t gone through. The pharmacy needed prior authorization. The authorization required documentation that technically existed, just not in the way it needed to. The specialist we referred her to asked for labs she had already completed but weren’t visible on their end.

By the time she sat back down in front of me, we were not building on the last visit. We were retracing it. So we made the same decision again.

That experience has been sticking with me, mostly because it does not feel unusual anymore.

As physicians, we are trained to make decisions. We gather the information, weigh the options, talk things through with our patients, and come to a plan. There is a moment at the end of a visit where it feels like something has been settled. But more often lately, that feeling does not last.

Care now moves through more systems and checkpoints than it used to, each with its own requirements for how a decision has to be documented and passed along.

Somewhere between the visit and the next step in care, the decision starts to loosen. It needs to be re-documented, re-explained, or approved in a slightly different way. Sometimes it is a small hurdle. Sometimes it is enough to stop things completely. And when the patient comes back, we find ourselves right where we started.

It shows up in all kinds of ways. Medications that get delayed for reasons that are hard for patients to understand. Referrals that stall even when everything was done correctly. Plans that depend on a series of steps that do not quite line up from one place to the next.

None of this is dramatic on its own. But it adds up. From the outside, it can look like duplication. From the inside, it feels more like maintenance.

We are not just making decisions. We are keeping them alive.

We resend notes. We answer followup questions that we thought we had already addressed. We rephrase the same clinical reasoning so it fits the format someone else needs. We try to anticipate where things might fall apart and patch it ahead of time.

It is not the kind of work anyone really talks about, but it takes time. And it quietly shapes how care actually unfolds.

There has been a lot of conversation lately about how technology might help. And in some ways, it already is. It is getting easier to pull information together, to document visits, even to think through complex problems more efficiently.

But I have started to notice something: getting to the decision faster does not necessarily change what happens after. If the plan still has to be rebuilt at the next step, the overall experience does not feel much different for the patient. We may have saved a few minutes during the visit, but we have not changed the part that slows everything down.

The problem is not just making the decision. It is whether it holds. And right now, that is not something we can count on.

It depends on whether the next system sees what we saw. Whether the documentation lines up with a specific requirement. Whether the information shows up where it needs to, when it needs to.

Each handoff introduces a little bit of uncertainty. Most of the time, we work through it. But when it does not go smoothly, the work circles back. We revisit the same plan. We explain it again. We move it forward another step and hope it sticks this time.

Patients feel this, even if they do not describe it in those terms. They sense when things are not moving. They lose time. Sometimes they lose confidence.

For physicians, it adds a quiet layer of fatigue, where the work is less about moving care forward and more about keeping decisions from falling apart. And over time, it changes how we practice too. You start to assume that a decision is not finished when you make it. It is only finished once it makes it all the way through.

We still make good decisions. That has not changed. But more and more, I find myself wondering something I did not used to think about: Not just whether the decision is right, but also whether it is going to last.

Because if it does not, we will be right back where we started. Making it again.