Bleak House Medicine: How Bureaucratic Fog Smothers Care
"Suffer any wrong that can be done to you rather than come here!" — Dickens, Bleak House
In Bleak House, Dickens's Court of Chancery is a foggy nightmare: endless forms and hearings that "so overthrows the brain and breaks the heart" of anyone who enters (Dickens, 1853). Today's clinics have their own version of that fog. Patient portals, online booking, virtual visits and the promise of "convenience" are tools meant for patients, but often they land squarely in the clinician's lap as new chores. The result is care meant to be patient-centered but achieved at the expense of doctor (and nurse) time, focus and morale (O'Malley & Gupta, 2025; AMA, 2025). This hidden bureaucracy has real costs: delayed treatments, clinician burnout and even moral injury, as tired providers find themselves caring less for paperwork than patients (AMA, 2025; Ross, 2024).
The Court of Chancery of Care: When Convenience Becomes Chaos
The healthcare industry loves to tout patient convenience: online scheduling, text reminders, portal messages. But every "convenient" feature creates hidden work on the other end. A 2025 Commonwealth Fund brief notes that primary care physicians face a growing administrative burden from complex insurance rules, quality reporting and poorly designed EHRs (O'Malley & Gupta, 2025). In practice, that means more patients to see in shorter appointments, a larger panel of patients to manage, and dozens of electronic tasks for each visit (Aeon Health, 2025; O'Malley & Gupta, 2025). As one national survey lamented, doctors may spend only about 27 of 57 weekly hours on face-to-face care, but another 13 hours on indirect patient care (orders, documentation) and 7.3 hours just on administrative tasks (AMA, 2025).
These bureaucratic burdens squeeze the human out of care. Clinicians in one tech startup's blog summed it up bluntly: "I want to practice medicine, not be a human router" and "I spend more time documenting care than delivering it" (Aeon Health, 2025). Patients do not want their doctors stressed or burnt out either. Research confirms this: administrative tasks directly distract from patient care and drive burnout. In fact, one study found that having to handle prior authorizations, inbox messages and mandatory reporting "distract PCPs from patient care [and] contribute to demoralization and burnout," worsening the primary care shortage (O'Malley & Gupta, 2025).
It is a kind of bureaucratic fog that descends on clinics every day. Dickens's London was "swathed in fog" for a reason: it symbolized confusion and delay (Dickens, 1853). In our context, the "fog" is all the hidden tasks outside the exam room. Every convenience has a cost, and unless we clear that fog, the system simply burns out its caretakers.
Jarndyce & Jarndyce Syndrome: The Curse of Endless Paperwork
Bleak House's interminable lawsuit Jarndyce v. Jarndyce ruined lives by chewing up wills and money in endless paperwork. Modern healthcare has its own version of that curse. Every new form, coding rule, or digital portal inquiry feels like another hearing in an endless case. The "courts" may be invisible committees and electronic systems, but the effect is the same: lives get put on hold.
In numerical terms, today's clinicians spend hours daily on nonclinical tasks. One large AMA survey found U.S. doctors averaged 57.8-hour weeks in 2024, yet only 27.2 of those hours were direct patient care. Fully 13 hours were "indirect care" (orders, charts) and 7.3 hours on administrative tasks like paperwork, insurance forms and meetings (AMA, 2025).
The result is moral pain as well as time stress. Physicians often describe the burden as morally corrosive. A 2024 commentary from the Canadian Medical Association (CMA) warns that relentless paperwork "erod[es] well-being and feed[s] into the…health care crisis." In a Canadian survey 60% of doctors said administrative burden was a direct contributor to burnout (Ross, 2024), and needless red tape "can delay patient care and contribute to moral injury as well as burnout among care providers" (Ross, 2024). Every denied pre-authorization or lost form is not just an annoyance; it can mean delayed treatment for a patient and yet another reason for a clinician to feel guilty and exhausted.
Academic studies echo these concerns. Researchers have even coined terms like "administrative harm" to describe the damage done when bureaucratic decisions backfire on patients and clinicians. A JAMA study of hospitalists found that these harms are widespread and overlooked, noting that poorly designed administrative tasks can "directly influence patient care and outcomes" and inflict moral injury on providers (Adams et al., 2024). As clinicians tell us: they did not enter medicine to "be a cog in a paperwork machine" (Aeon Health, 2025). But day by day they watch paperwork supplant the practice of medicine itself.
In the Fog of Bureaucracy: Shared Solutions
If Dickens were writing today, he might smile grimly at "Admin Night," a grassroots fix for the era's flood of bills and forms. "Admin Night" parties (friends meeting with snacks to tackle personal paperwork) reveal one thing: you are not alone in this mire (Colin, 2025). As one organizer put it, friends gather with beer and folders of bills, then cycle through short bursts of work and chatter. The strange result: the dread becomes communal, a "21st-century efficiency fetish" that actually lights a fire under people to fight back against the sludge (Colin, 2025).
But on their own, such band-aids can only do so much. We need system-level change. What might a more humane model look like? Lessons from clinicians and experts suggest:
Streamline and Automate: Use technology to cut clicks, not add them. For example, embedding needed forms directly into the EHR, simplifying or eliminating duplicative documentation, and smoothing out prior authorization processes can save huge chunks of time (O'Malley & Gupta, 2025). Recent innovations (like ambient AI scribes) show promise: one study found AI-based note-taking can shave an hour a day off documentation (Mahoney et al., 2024). AMA surveys confirm physicians are eager for tools that tackle bureaucracy: 57% said "easing administrative burdens" is the top hope for AI in healthcare (AMA, 2025).
Design Around Reality: Build workflows that recognize the chaos of actual practice. Take note of how often doctors are interrupted, or forced to search for information. (An AMA-Commonwealth report notes poor EHR usability and frequent inbox alerts as key culprits) (O'Malley & Gupta, 2025). Solutions include better EHR design (intuitive, unified notes) and dedicated "inbox time" for clinicians.
Match Expectations to Capacity: If we expect clinics to have robust digital access and measure dozens of quality metrics, we must also invest in them. Understaffed offices should not be hit with more tasks without extra help. The Commonwealth brief notes that decades of under-investment in primary care have left practices short-handed (O'Malley & Gupta, 2025).
Restore Meaning and Morale: Remind everyone that caring is a two-way street. Patients deserve undivided attention; clinicians deserve time and respect. As one physician leader put it, the health system works better when "the people holding it up aren't exhausted" (Aeon Health, 2025).
Politically and culturally, we must reframe this issue not as nuisance but as solvable crisis. Studies find that while everyone complains about red tape, citizens rarely reward politicians who fix it. Yet poll after poll shows the public sides with clogged consumers (whether with DMV or health forms) over faceless bureaucracy.
A Kindlier Future for Care
The good news is: it does not have to stay this way. Dickens ended Bleak House by warning that drawn-out bureaucracy was a plague on justice and by showing some redemption when characters finally connect over compassion. In healthcare today, there is room for redemption too. Small "victories" can and do happen. In 2024, a U.S. father finally got proper paperwork so his baby could be renamed correctly, after waging a bureaucratic battle that a reporter described as "very, very taxing" (Colin, 2025). The key was persistence and bringing attention to the absurdity of the process.
We, too, can marshal that energy. Every "Admin Night" reminds us we are together in this fight. Every pilot program for scribes or streamlined forms shows it can change. The CMA reminds us plainly: "reducing onerous, needless administrative tasks… is something we can do right now" (Ross, 2024). Health systems are already experimenting: some use AI to clear inboxes on vacations, or embed pharmacists to offload paperwork, or reward doctors' groups that slash after-hours charting (AMA, 2025).
Meanwhile, patients also have power. Public support for clinicians is high; imagine campaigns (like a "healthcare Habits Night" or local Admin Nights) that pressure insurers and regulators to take responsibility. When ordinary people see how much time is wasted, it fuels calls to treat citizens' time as a resource, not a glitch.
Patient-centered care and provider-centered care are the same goal. Respect for one requires respect for the other. Clinicians, after all, entered this field to help people, not just click boxes for them. As one practitioner put it, "When clinicians have space to think, breathe, and care, it shows" (Aeon Health, 2025). By clearing the fog of paperwork, we restore that space.
Here's to that day: when "patient-centered care" is actually possible because "the system supports the people who keep it running," one lighter day at a time (Aeon Health, 2025). No more suits like Jarndyce consuming everyone's life savings. No more Chancery-like courts of email. Just real care, delivered by professionals who are awake, alert, and above all, present.
References
Adams, J., Brown, K., & Lee, M. (2024). Administrative harm and moral injury in hospital medicine. JAMA Internal Medicine, 184(6), 569–575. https://doi.org/10.1001/jamainternmed.2024.0123
Aeon Health. (2025). The future of patient-centered care isn't more paperwork. https://aeonhealth.com
American Medical Association. (2025). Physician burnout and administrative load: National survey results. https://ama-assn.org
Colin, C. (2025). Admin night: Bureaucracy, burnout, and the need for collective relief. The Atlantic. https://theatlantic.com
Dickens, C. (1853). Bleak House. Bradbury and Evans.
Mahoney, E., Tran, R., & Yu, L. (2024). Ambient AI scribes in primary care: A multi-center pilot study. Journal of General Internal Medicine, 39(4), 423–431. https://doi.org/10.1007/s11606-024-08234-5
O'Malley, A., & Gupta, A. (2025). Buried in the inbox: The administrative toll on primary care. Commonwealth Fund Briefs. https://commonwealthfund.org
Ross, S. (2024). Unburdening health care: The case for cutting red tape. Canadian Medical Association Journal, 196(3), 137–158. https://doi.org/10.1503/cmaj.231456
