WHEN DEFAULTS DECIDE FOR US

What my software “upgrade” has to do with your doctor visits

Photo by Andras Vas on Unsplash

This week I finally did something I’d been avoiding: I migrated my practice accounting software from the original desktop program to the shiny online version.

I consider myself pretty tech savvy; so I wasn’t afraid to upgrade to online. But, I’m of the opinion if the old system still works, why change; however, when my accountant said, “The support for the desktop version is going away; you really need to move online,” I sighed, rolled up my sleeves, and did it.

A few clicks later, my data is moved and—like magic—I’m dropped into the “premium” version with all the bells and whistles. Free trial. Limited time. With all the best features, of course.

I knew I didn’t need all of it. I know what my practice actually requires, and it’s not the Cadillac package. So I did what any reasonable practice owner does: I tried to downgrade.

I called support. They were pleasant. And the answer was predictable:

“Don’t worry about it, it’s just a free trial. You can always downgrade when the trial is done.”

Nah. That wasn’t going to work for me.

Because I’ve seen this movie before.

The “free trial” that never really ends

This is the same carrot‑and‑stick game medicine has been playing with physicians for years.

Back in 2009, the HITECH Act (Health Information Technology for Economic and Clinical Health Act) poured federal money into pushing electronic medical records and e‑prescribing. It offered financial incentives if you adopted “meaningful use” of certified systems and penalties if you didn’t, all in the name of modernization and better data.

On paper, it sounded like a win: upgrade your tech, get paid to do it, join the future. In retrospect, the reality of those “incentives” weren’t rewards; they were bait. Once you were inside—after the money, the training, the workflow rewiring, the emotional energy—walking away became nearly impossible. The default became the new norm, and the cost of escape was engineered to feel higher than the cost of staying, even when staying was miserable.

This little software “upgrade” works the same way: give you everything so you get used to it, assume you’re too busy to revisit the details, and then let inertia quietly turn a trial into forever.

Sound familiar?

Designed for doctors who are too busy

The casual line “You can always downgrade later” rests on one assumption: you have time and attention to spare.

But private practice physicians live in constant triage—managing inboxes, prior auths, staffing issues, compliance requirements, and everything waiting at home after clinic. We are responsible, smart, and completely overextended, which makes us the perfect targets for “set it and forget it” traps.

While we’re buried in the day‑to‑day, other changes quietly creep in. The language shifts from “physician” to “provider,” flattening years of training and professional judgment into a generic service role. Visit length shrinks, documentation demands grow, and new checkboxes appear in the name of “quality” and “metrics.” Every small change is presented as harmless, temporary, or “just the way the system works now.”

Individually, these things look minor: a new portal, a new measure, a new script for how we introduce ourselves. Taken together, they teach us to accept less autonomy and more oversight as normal. When you’re already stretched thin, a “free trial” that auto‑converts or a title change you didn’t ask for isn’t a favor—it’s a bet that you’re too busy or too tired to push back.

That’s not just a software tactic. That’s the operating system of modern medicine.

What I did differently this time

So when support told me, “You can always downgrade later,” something in me bristled.

No. That’s exactly how we got trapped before.

This time, I asked to be downgraded right away, even if it meant fewer “features.” I chose the plan that actually fit my needs, not the one they hoped I’d grow into. And I refused to confuse more features with more freedom.

At one point, the support person said, “You have a choice.”

I had to laugh.

I told them, “Actually, I don’t. I was forced to move because you’re no longer supporting the desktop version.”

On paper, it looked like a choice. In reality, the decision had already been made for me. I was just choosing which version of the new box I wanted to live in.

Is it a small thing? Yes.
Is it symbolic? Absolutely.

This wasn’t just about software. It was a reminder that I’m allowed to choose the simplest tool that does the job—and that I don’t have to accept defaults someone else designed for their profit and my distraction.

Direct care as a deliberate “downgrade”

Direct care and physician‑owned models are, for me, an intentional “downgrade” from the bloated, feature‑heavy way we’ve been told to practice. I didn’t choose this path because I wanted to be fancy or “boutique.” I chose it because I went to school to be a doctor, not a glorified data entry clerk.

In direct care, I get to strip away the layers that never actually helped my patients: the middlemen, the portals that create more messages than they solve, the multiple logins it takes just to send in a prescription or see a lab. I trade the illusion of “robust features” for something much more basic and much more valuable: time to sit, look a patient in the eye, and think.

I’ve written before about how much I value knowing my patients’ stories—how their work, their shoes, their caregiving roles, their stress, all show up in their feet and in their health. That kind of care doesn’t happen in seven‑minute slots with three different screens demanding my attention. It happens when I own my schedule, set my own visit lengths, and decide that the relationship matters more than the insurance carriers’ RVUs (relative value units).

Direct care also lets me be honest about money. I can say, “This is what it costs, here is exactly what you get, and here’s why I recommend it,” without a third party silently changing the rules in the background. That transparency is a “downgrade” from complex fee schedules and secret pricing, but it’s an upgrade in trust.

So yes, on paper, my model looks “basic” compared to all the bells and whistles the system wants me to plug into. But basic on purpose is the whole point. It’s how I protect my ability to think clearly, care deeply, and actually be your doctor—not just another “provider” clicking through someone else’s default settings.

What this has to do with you as a patient

If you’re a patient reading this, you live in this same world of “free trials” and default settings.

Your phone, your streaming services, your insurance plan—they all quietly assume you’ll stick with whatever is easiest to click “yes” to. Over time, those small defaults shape your choices: what care you think you’re “allowed” to get, which doctors you see, how rushed your visits feel, and how much access you really have.

When I fight to downgrade the software in my practice, I’m trying to protect my ability to notice you, listen to you, and think clearly about your care instead of clicking boxes for someone else’s system. My “basic on purpose” isn’t about cutting corners; it’s about cutting noise.

One tiny autonomy move for your week

Here’s my challenge for you this week—whether you’re a doctor, a patient, or both.

Pick one “free” or “included” thing in your life: a subscription, an add‑on in your insurance plan, a default setting in an app, a rushed 7‑minute office visit you’ve started to accept as normal. Ask yourself: Who does this really serve? If I were starting from scratch, would I pick this?

If the honest answer is no, take one small step. Cancel something you don’t need, ask for a longer visit, request a clearer explanation, or explore a practice model that actually gives you access to your doctor instead of just access to a portal.

You don’t have to overhaul your entire life or practice to reclaim autonomy. You can start by refusing one carrot you never asked for in the first place.