14 November 2012

Write this down for me

I have a lovely pen. It's a Mont Blanc Meisterst├╝ck fountain pen. My group bought it for me on my tenth anniversary as a partner in our Emergency Medicine practice.

It's a luxury I would never have paid for myself, though I have loved and used fountain pens since I was in college. Ironically, about the time I got it, the window of opportunity to use it in my professional life closed. For a decade, we had a hybrid paper-and-dictation documentation system, but around the time I hit my milestone, we went to an Electronic Medical Record (EMR). And with that, I never again had to touch pen to paper, except to sign the odd prescription. Such is life.

I am a computer guy, tech-savvy and fearless, and I was one of the few docs who saw the move to an EMR as a good thing.  My documentation improved, and now that we are with Epic I would say it's even better. As I am a quick typist, the workload of documentation was only modestly increased by the transition to full physician documentation in the EMR. The other docs in my group varied in how well they adapted, from a few whose productivity improved, to the mass who accepted it with grumbles and minor complaints, to a few outliers who simply refused to use it at all.

Recently, though, we started a pilot program using medical scribes.

Honestly, I resisted the scribe initiative for years, though there were a few docs who really wanted them. I wasn't opposed, but I was too busy to do it, and it wasn't high enough on my priority list to make it happen. It finally happened when I challenged one of our younger, energetic docs to "make it happen," and she went out and did just that. Very impressive initiative. She formed a committee, put together a business plan, had presentations from scribe vendors, took competitive bids, and soon enough there were young enthusiastic faces greeting us in the ER. I watched, bemused, from the sidelines for a couple of months and finally took the plunge and signed up for a scribe myself for a few shifts.

These are my thoughts and observations so far, after about a dozen shifts with my own personal scribe.

First, the general structure of the program, for our group. We pay a flat hourly rate to a scribe vendor. The vendor recruits the scribes from a local university, mostly pre-med students, and manages all the HR functions associated with such a program. Docs who are interested in having scribes sign up and choose which shifts they want a scribe for. The cost of the scribe is deducted (pretax) from the doc's individual paycheck. The program is entirely voluntary and about a third of our docs have signed up so far, usually just for the busier shifts.

The social aspect of having a scribe is more than a little weird, though I got used to it quick enough. I added another line to my standard introduction: "I'm Dr Shadowfax, and this is Jenny, who is working with me today." Almost never has the presence of the scribe occasioned any further comment or discussion. The scribes step out of the room for pelvics or other uncomfortably intimate exams and are generally invisible during the H&P (hidden by the large monitor of the computer on wheels they bring with them). During the physical exam, I verbalize what I'm seeing/doing, as if I am talking to the patient. "Your lungs are clear and your heart is regular without murmurs." This allows the scribe to document my exam in real time, and, from what I can tell, patients seem to like it, since they are getting a sense of what I am looking for and seeing. If there are "issues" such as psych, substance abuse or simply an unpleasant patient, I'll wait till we're out of the room to tell the scribe what I want documented.

I've never had a secretary or personal assistant before and have always prided myself on self-sufficiency, so it feels odd to have someone whose whole job is to do the little scut work (like putting a chart in the rack or pulling reports off the fax machine) for me. I can do that perfectly well myself. I can also document perfectly well myself. Better, in fact, than most. Getting over the idea of someone else doing "my" work for me has been and remains probably the biggest barrier for me in fully accepting the scribe. But these small efficiencies are of course the whole purpose of having a scribe in the first place, so I am getting over that.

The workflow is quite different now. It's actually very pleasant. I have the freedom to simply sit down and talk to the patient. I can take a bit longer and have more of a free-flowing conversation. I'm facing the patient, not facing a computer screen, I'm not making notes on a clipboard, and I'm not frantically trying to remember the necessary data points for the chart. I just chat. I feel like I have more mental energy to spend on the patient and I can simply forget about the chart, confident that the scribe is capturing the important data points. Simply put, I can focus on the patient, and I feel like that allows me to be a better doctor. I suspect, though I have no proof, that it also helps with patient satisfaction, which matters a lot these days.

The quality of the documentation is a little more variable. It's hard to let go of control of the chart. There are some odd little verbal tics some of the scribes have that I would never use. To me, reading these charts are like fingernails on a chalkboard, though they're perfectly accurate and acceptable. Sometimes a really important historical point gets left out of the chart because the scribe didn't realize its significance. It is very important to proofread the charts and make sure they say what you need them to say. I'm learning to "let go" and not spend so much time editing each chart that it negates the point of having a scribe in the first place. And I think the scribes, as they learn, are getting better and better at picking out the important bits of the conversations they are documenting. When there is an important point I want emphasized I can simply repeat it back to the patient as a cue that I want this verbatim in the chart, and if I note an omission I review that afterwards with the scribe as a "teaching point" for them, as I would with a med student. Since they are all pre-med, they really seem to appreciate it. One of the best points (and a pleasant surprise) was when I reviewed my charts and found entries like:

1645 - patient re-evaluated. Abdomen still nontender. Taking po well.
or, 1015 - neurosurgery paged. 1025 - Dr Shadowfax speaking with Dr Jones, who requests MRI

Stuff that I had never before had the discipline to document and time, now 100% of the time in the chart. This is a huge benefit, especially when it comes to med mal defense.

Another thing that this has forced me to do is be more rigorous with my H&P. Once you have been working in an ER for a while, there are quite a few diagnoses you can literally make from the doorway. Say, a kidney stone. I don't need to do a Review of Systems or even a physical exam for a kidney stone patient, and over the years I may have become a little lax on this point from time to time. But we have trained the scribes that "if it didn't happen, you cannot document it." So now, knowing that the scribe cannot document a complete ROS unless I actually did that ROS, I am more compulsive about making sure I hit all ten systems. (Even when it's not clinically relevant. Such is the Kafkaesque world we live in.) And I make sure to do a full exam where before I may have elided over a few systems. This is, of course, only for cases where the complexity of the case will justify a service level requiring the complete H&P. So the scribe effectively helps keep me honest and improves my compliance.

The productivity side is also a net positive. Once I learned to let go and trust the scribe to get all the charting with minimal oversight, this freed up my time enormously. I can go from room to room to room seeing new patients, with only a brief interlude to enter orders (which the scribes are not allowed to do in our hospital). I've always been able to see 2+ patients per hour with no problem, and with the scribes 3+ has been easy, when volumes permit. I think I could go even higher but I haven't had a really busy shift since the program began.

At this point I am, I think, not making money on the scribes. I think, in fact, that I am losing money. I have been told by experts that in the startup phase of a scribe program you should expect to lose money for the first year. This seems reasonable with our experience. We have 8 docs on duty in our ER at peak times, and only a fixed number of patients. To the degree that I can see more patients, that's taking money from my partners' wallets, which puts an upper bound on my appetite, out of courtesy. Worse, if I have a scribe on a slow shift, it grates on me that I am paying for them do essentially do nothing. If I have a scribe, I feel pressure to be more productive than I otherwise would. Over time, I hope, we can contract physician staffing to the point that we will all realize increased productivity and revenue. This requires more than a 1/3 physician buy-in, which we have yet to achieve. We will see. For the moment, I can at least hope to break even on the program, though some of it may come at my partners' expense. Maybe that will induce them to get their own scribes as a defensive measure.

The final, and perhaps most important, point for me is this: quality of life. If I have a scribe shift, it's a good shift. I save so much mental energy not having to chart. When I have a five-minute conversation with a patient, ordinarily, I am carefully committing about 30 key points to my short-term memory. I then have to dash out of the room, while it's still fresh in my mind, and enter that into the computer. I never realized how much that was wearing me down till I didn't have to do that any more. My "external memory" is passively (from my point of view) capturing all these data points and I can focus on my clinical impression from the get-go. I can forget the details and focus on the big picture. The saved "brain strain" takes a busy shift and makes it seem nearly effortless. When I have five free minutes, which is rare enough, I can check twitter or my email or text my wife rather than frantically trying to catch up on my charting. And when my shift is over, I am generally done with my charts and can walk out the door as soon as the last patient is dispo'd. Granted, I was generally one to leave at the end of my shift even without a scribe, but that took work. Now it's easy. I like my job better. I've never felt like I was one of those docs susceptible to burnout, but it is endemic within emergency medicine, but for someone who is riding that razor's edge, a scribe could be the difference in job satisfaction between having to leave the field and keeping their career going another decade.

I'll update this when I've more experience, but so far I am continuing my scribe utilization and would describe myself as very happy with the experiment. Now I just need to figure out how to get them to blog for me.


  1. What do patients and families think?

    I have mixed feelings about scribes, although I recognize there are different dynamics in the ER vs. office practice.

    My experience with a medical scribe involved an office visit with a family member who had a rare complication during surgery and had to come back for an office visit a couple of days after leaving the hospital.

    The room was not very large and there were only 3 chairs - one for the patient, one for the doc and one for the scribe. I had to stand in the corner (and I mean this literally) for the entire visit.

    Our reason for being there was due to unfortunate circumstances - not the surgeon's fault, I hasten to add, but the situation was obviously not a happy one and having another person in the room taking notes felt somewhat intimidating. We did not know there would be a scribe recording the visit, and to have two people parading into the room and taking over the chairs and the desk can come across like a tactical maneuver to establish who's dominant, whether this is what's intended or not. Plus the clickety-click of the scribe's keyboard was distracting, on top of what was already a rather stressful visit.

    Having a scribe may be convenient for the doctor, but the presence of a third party *in real time* can really alter the dynamics of the encounter in subtle ways that are negative for the patient. Will patients be as frank as they need to be when there's someone else in the room? I don't think I would be, although I speak only for myself.

    Again, the dynamics are probably very different in an ER setting. I just hope doctors recognize that what seems like a great thing for their own work flow and efficiency is not always experienced the same way by patients and families. Hopefully your ER is getting some feedback and is willing to tweak the system so it's comfortable for everyone.

  2. Dr. Greenbbs11/14/2012 9:44 PM

    We have had scribes in my ED since I arrived. I think they are fantastic. Since I am a hospital employee, our dept pays for them and it doesn't come out of my salary. I see more per shift and get out on time every shift. I am one of the faster guys so I tend to get the more experienced scribes, so it takes the variability out of the documentation. We see 120k per year ,and I couldn't imagine working in my Ed without them.

  3. I am a family doctor at a Community Health Center (on a salary), so scribes are about the furthest thing from our budgetary considerations. However, I really liked the point-of-view of using it as a tool to stave off burnout and extend physician careers. I seriously doubt it's anything that ACA/health reformers have ever thought of, but allowing physicians to work only at our highest level rather than function as secretaries for a significant portion of our working hours (lives) might do a lot to stretch our limited resources further.

  4. The ER I worked in prior to traveling made the transition to using scribes. Most of the docs loved it, for the same reasons you just listed. Another positive was that since they did the charting, the docs had more time to focus on the many interruptions required of them - from nurses relaying critical values to consults to overhead pages - since the HPI is already charted they didn't have to dash back to the computer before forgetting the interview.

    There were a few that didn't like to utilize the scribes, but they tended to be the docs who worked super fast anyway - or the grouchy ones who didn't like the extra communication required...

  5. I've worked around docs using scribes at a couple places, though we'll never see them where I am now, and they seem to work well. They make (at least some) docs more efficient and faster, and it seems like they probably pay for themselves in allowing the doc to see more patients. Patients don't seem to notice them much, and if they do they figure they are a med student or something.

    By every metric I can think of they are a good thing, but it still just seems weird.

  6. So this should free up time for more blogging, right?

    This and your next post explain a question I have had for sometime. And while it may not apply to emergency medicine, scribes may help specialists really drive up their income.

    I got out of the hospital with my second case of DVT/PE's. On the CT scan they noticed tumors on my thyroid. So I had a follow up with a ENT for the thyroid and a vascular surgeon to see if he could do anything. It was explained to me that they would want to do a biopsy on the thyroid and then even if it came back negative, they would most likely want to remove the thyroid anyway. This made no sense that I would have to get off the warfarin to get the biopsy, then get back on then get back off when they removed the thyroid. So I had one simple question, why not just remove it to begin with? I was told I had to schedule a consult. It was the first time I ever had anyone other than a nurse in the exam room with me and the doctor. So while I asked the one question that I had, he proceded to do a pretty full ENT exam and try and sell me on deviated septum surgery (though it was very minor and never a problem). I spent about a total of 7 minutes with him and my insurance company paid nearly $600 for that visit.

    Then, I saw the vascular surgeon and though he couldn't do much for me, he spent a good 20+ minutes with me explaining the issues and problems. His bill was about 1/2 of the ENT's.

    I had attributed this discrepancy in fees to your previous posts about how some specialists have more pull when it came to determining complexity and the associated fees.

    I now realize, the scribe was there so he could document all the things that he did other than just answering the one simple question that I needed to know!

  7. This looks like another place where an HIM type (eg, transcriptionist) could fill the bill, if that turns out to be more profitable than a med student. OTOH, I can see the benefit for med students, somewhat like altar boys feeling around for a vocation to the priesthood.