There's no way I've been the only one to think this.

You're in the monthly group meeting. The medical director pulls up a slide. "We need to start documenting XYZ in every note — compliance/billing/risk management wants it." Nobody asks where the time is supposed to come from. Nobody ever does. To be fair, it's usually a minor ask. But so was last month's. And the one before that.

"Timestamp your sepsis reassessment times." "If thrombolytics weren't given within 1 hour in a code stroke, document which contraindication they met or why you didn't give it." And so on and so on. Then, without a hint of irony, next slide: "Our door-to-doc times dropped two minutes this month. We need to pick it up."

More documentation. Less time. Both delivered with a straight face in the same breath.

But you're an ER doc. You already know exactly what this feels like. You've lived some version of it every month for your entire career. And if you've ever sat in one of those meetings thinking "this is insane," congratulations — you're paying attention. Because the documentation burden in emergency medicine isn't just a nuisance anymore. It's a structural crisis that's quietly hollowing out our specialty from the inside.

The Math Doesn't Work (and Everyone Knows It)

If this stuff depresses you don't read the data on it. The average physician in the United States now spends roughly 37-45% of their entire workday on EHR tasks. Not seeing patients. Not making clinical decisions. Clicking, scrolling, documenting, and re-documenting things that have already been documented — charting reviews of systems that don't change the plan (yes, even with the 2023 changes some systems still require it), satisfying billing thresholds that have nothing to do with clinical reasoning, and checking boxes that exist because someone in a conference room three time zones away decided they should exist.

In the ED specifically, the numbers tell a story that should make everyone uncomfortable. Emergency physicians spend a median of 6.82 minutes on the EHR per encounter, with more than three times as much time devoted to documentation as to chart review. That clock goes up with patient complexity, higher acuity, handoffs between physicians, and admission decisions — which is to say, it goes up for the exact patients that already demand the most of your clinical attention. The sickest patients generate the most documentation burden. Think about how backwards that is.

Then there's pajama time. Over 22% of physicians report spending more than eight hours per week on EHR work outside of normal hours. That's after the shift. At home. Missing dinner, missing bedtime, staring at a screen finishing charts from patients you saw six hours ago while the clinical details fade and the documentation becomes an exercise in reconstruction rather than communication.

You're not seeing twelve scheduled patients over an eight-hour clinic day. You're managing a department — multiple patients simultaneously, constant interruptions, new arrivals, critical results, reassessments — and somehow you're expected to produce the same caliber of documentation as an outpatient provider with a scribe, a template, and one patient at a time.

The system demands thorough documentation. The system demands speed. The system never once stops to acknowledge that these two demands are in direct conflict, and that the person absorbing that conflict is you. And, of course, if god forbid you get sued, you already know that "I was getting crushed that day; something had to give and it was either my multiple unstable patients or my note quality, and I chose note quality," is not a valid legal defense.

"Add This to Your Notes"

We all have a running mental catalog of things that have been added to "the note" over the years. Most arrived with an at-least semi-defensible reason. Each one added time. And not a single one came with a corresponding reduction in anything else.

Timestamp your sepsis reassessment after IV fluids. Face to face timestamped for all restraints. Did you get the ID number of that remote interpreter?

Individually, each of these is at least somewhat reasonable. Collectively, they've turned the emergency medicine note into a compliance document that occasionally contains clinical information. Researchers who studied EHR workflow in the ED identified six overlapping categories of burden: lack of advanced EHR capabilities, absence of optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages. That's not one problem with six symptoms. That's six distinct ways the system fails the people using it.

The note has become the primary product of emergency medicine. Patient care has seemingly become the side hustle.

This Is a Burnout Engine

Emergency medicine consistently reports among the highest burnout rates of any specialty, we all know this but it bears repeating. The published prevalence in EM ranges from as low as 10.5% to as high as 70% depending on which study you're looking at and how burnout is measured, but the most recent large surveys consistently place it well above 50%. Behind those numbers, the pattern is always the same: high workload and administrative burden are identified as key drivers, over and over again, across every study design.

People. Read that again. Half of all of us are burned the fuck out. I've been out of residency 3 years and I feel it. I fight that feeling every day. Almost every ER doc I know is actively looking for a way out of this job: open up a wellness clinic? Real estate investing? Fellowship? Bitcoin (not even joking). I have the exact same conversations with basically everyone in our specialty. Just finished residency, attending for 20 years, doesn't matter. Most of us are looking for the door.

And here's the part that should stop every hospital administrator in their tracks: it's not the clinical work causing this. Qualitative studies of ED physicians consistently identify heavy workload, frequent interruptions, and feeling undervalued by leadership as the dominant organizational factors. The hours spent on documentation specifically contribute to loss of autonomy, lack of work-life balance, cognitive fatigue, and poor relationships with colleagues. The charting doesn't just take time. It corrodes everything around it.

The downstream effects are measurable. In academic emergency departments, 89% of physicians have reported that documentation requirements decreased their teaching time. 79% believed their clinical efficiency was reduced. 80% experienced decreased job satisfaction. That's not a fringe complaint from a vocal minority. That's near-universal agreement that the documentation burden is making us worse at our jobs and less satisfied doing them.

And burned out physicians don't just feel bad — they leave. Replacing a single physician costs up to $500,000 in recruitment, onboarding, and lost productivity. We're hemorrhaging experienced ER docs not because the clinical work broke them, but because the charting and other garbage did.

Note Bloat: Longer Notes, Less Information

There's a particular insult embedded in all of this. The notes we're killing ourselves to produce are often clinically useless.

The phenomenon has a name: note bloat. Notes balloon with auto-populated fields, templates and click boxes galore. The result is a ten-page document where the actual clinical reasoning — the part that matters — is buried under layers of auto-generated noise. If you're at a center that takes transfers you've seen these psychotic mountains of paperwork. You gotta read a whole book to find the one MDM paragraph from the transferring doc, and pray that it's formatted in a fashion designed for an actual human to read.

When CMS and the AMA rolled out new coding guidelines aimed at reducing this problem, ED note length dropped by an average of 872 words. That sounds like progress — until you see that documentation time didn't change significantly. The length was a symptom, not the disease. Physicians spent the same amount of time charting even when the notes got shorter, because the underlying workflow — the clicking, the navigating, the checkbox-checking, the system-fighting — remained exactly the same.

You can trim the note all you want. If the process of producing it is still broken, the burden doesn't move.

The Contradiction Nobody Addresses

Here's what makes this uniquely frustrating: everyone in the room knows the system is broken. The medical directors handing down new documentation requirements know it. The administrators tracking door-to-doc times know it. The compliance officers know it. The billing department knows it.

But the machine keeps running because nobody has the authority — or the incentive — to pump the brakes. Compliance needs what compliance needs. Billing needs what billing needs. Quality metrics need what quality metrics need. And the physician is the only common denominator in all of these equations, so the physician absorbs every new requirement while the expectations on the other side of the ledger never decrease.

You can't add fifteen things to a note and then wonder why it takes longer to see new patients. You can't keep loading weight onto the same person and then act surprised when they break.

But that's exactly what we do. Every month/quarter/however frequently your group meets. Every group meeting. Every new initiative.

This Isn't Just Complaining — It's a Design Problem

The temptation when you talk about documentation burden is to sound like you're just venting. Every doctor complains about charting. It's a meme at this point. But there's a critical difference between venting and identifying a system that's fundamentally broken.

The emergency medicine note, as it exists today, is trying to serve too many masters. It's simultaneously a clinical communication tool, a billing document, a legal record, a compliance artifact, a quality metric data source, and an administrative paper trail. The American College of Physicians has said it plainly: clinical documentation should primarily support patient care and improve clinical outcomes through enhanced communication, not serve billing and regulatory purposes first. And yet here we are, producing notes where billing and regulatory compliance come first and clinical communication is an afterthought.

No single document should serve all of those functions, and no single human should be responsible for producing it in real time while also running a department.

This isn't a willpower problem. It's not a time management problem. It's not something that gets fixed with a more efficient template or a faster typing speed. It's a design problem — and the only real solution is to fundamentally rethink who (or what) is responsible for the documentation burden.

The clinical reasoning should come from the physician. That's irreplaceable. But the mechanical act of translating a patient encounter into a compliant, billable, legally defensible document? That's a process. And processes can be automated.

The evidence already supports this. Human scribes have been shown to increase patients treated per hour, boost productivity by nearly 16%, and reduce median length of stay by 19 minutes in a multicenter randomized trial. Eighty to eighty-eight percent of physicians who work with scribes prefer it and report decreased likelihood of burnout. We've known for years that offloading documentation works. The limiting factor has always been cost and scalability — you can't put a human scribe in every ED, in every room, on every shift.

AI changes that equation. Early data on ambient AI scribes in the ED shows a 28% reduction in on-shift documentation time. The technology is young and adoption is still low, but the direction is clear: the documentation burden can be lifted without sacrificing the quality of the note.

The question is whether these tools were built by people who understand the problem — not just the technology, but the 2 AM reality of what it actually means to practice emergency medicine.

Something Has to Change

The documentation culture in emergency medicine is unsustainable. Not in the abstract, hand-wringing, "someone should do something" sense. Unsustainable in the concrete, measurable, people-are-leaving-the-specialty sense.

We can keep absorbing it. We can keep showing up to group meetings, remembering the new thing to add to our notes, staying late to finish charts, and telling ourselves this is just how it is. Physicians are resilient. We can take a lot. That's been proven over and over again.

But "we can take it" is not the same as "we should." And the fact that we've tolerated a broken system for this long doesn't mean the system isn't broken — it means we've been too conditioned to push back.

It's time to stop absorbing and start demanding better.

Sampson Medical is building the AI-powered scribe that emergency medicine deserves — designed by an ER doc who got tired of charting through dinner. No bloat. No bullshit. Just your note, done right.