My experience with a scribe in the emergency department

My experience with a scribe in the emergency department

I have a lovely pen. It’s a Mont Blanc Meisterstück 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.

“Shadowfax” is an emergency physician who blogs at Movin’ Meat.

Image credit: Shutterstock.com

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  • Peter Elias

    Thank you for the insights. I find it helpful. The use of a scribe is often suggested to make life easier in my (PCP) universe and I have not pursued this option. Your post nicely addresses some of my concerns. The biggest one, however, remains. And is probably not something that you would be able to address, as our practice settings are different. Almost all of my patients are people I have known over time and have a durable relationship with. There is an intimacy in the relationship that I think would be at risk with a third party in the room; it is even an issue with my nurse, who also knows the patient well. And a very large portion of what I do is psychosocial, pursuing how the patient is coping with their illness, relating to their family or colleagues, and the like. These are conversations that would not be as easy or comfortable with a third party present, and do not lend themselves to documentation based my my public narration. (“The patient notes some improvement in his comfort resisting inappropriate requests from his supervisor.”)

    I’d love to hear comments here from PCPs.

    • ninguem

      And healthcare is now, just that much more expensive, as we pay salaries of people just to write the notes.

      There’s something wrong with a medical system that requires someone just to write the note.

      • southerndoc1

        Let’s see. EMRs result in more tests ordered, more ER visits, more hospitalizations, and now require a full-time shadow for every doc. The savings just keep adding up.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        They don’t “write the note”. They collect data points for research and analytics.

        • ninguem

          Good. You can pay the scribe’s salary.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Agreed. There should be a CPT for that…. :-)

          • ninguem

            Just so long as you realize that healthcare is that much more expensive because of that. Every time the doc turns around, we get asked to “pay a little more”, the current administration saying “pay a little bit more”.

            There’s been talk about registering docs to do CDL exams for truck drivers, along the lines of the FAA medicals for the pilots. Once again, proponents of the system (their cottage industry), makes the flip remark that the docs will just “pay a little more” in fees (that previously did not exist), and they conveniently forget that it adds to the pile of nickels and dimes paid, that adds up to a lot.

            Just don’t complain that medicine is too expensive.

          • southerndoc1

            I think Ms. Gur-Arie agrees with you. Her point is that, contrary to the line we’ve been feed, EMRs are not about patients and doctors, they’re about data collection using docs as unpaid labor. That’s reality.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yes, thanks southerndoc…. maybe my feeble attempt at sarcasm was a bit misplaced….

          • ninguem

            I just noticed the CDL driver forms are now asking the doc for a registration number. So now we have to take an asinine course, creating still another cottage industry for PARASITES that suck money out of the medical system, providing ZERO value, wasting the doc’s time with an absolutely useless but mandatory course, and pay whatever fee will now be required, and the government is that much bigger, medicine is that much more expensive, and the flip smarmy parasites that created the new bureaucracy will say we “pay just a little bit more”.

    • MarylandMD

      Note that an ER doc is losing money and hopes to break even on the cost of a scribe. Given the compensation for primary care, it seems that the cost may be a significant problem.

      Cost issues aside, I share your concern about how scribes would go over with patients in a primary care setting. It probably wouldn’t matter for many acute visits (cold, flu, back pain, etc.), but what about someone coming in for a fall and you suspect an alcohol problem? What about a married man who comes in with herpes, and you have to ask him about sexual contacts outside of the marriage? What about the 24 year old first time mother with “fatigue” who you think is depressed and may also be the victim of domestic abuse? I am worried that having a 3rd party in the room will create a barrier to the open communication needed to get to the bottom of these issues.

      I said it in another thread, but when you think about it, it is nothing short of shocking that in order for us to adapt our patient care to having EMRs, we have to drag a 3rd party into the exam room!

  • azmd

    Remember when medical students did that sort of thing? For free? That’s why it is called a “clerkship.”

    Funny that it is no longer acceptable to have a medical student documenting your work, but it’s fine to have a pre-medical student who is being paid, do the same thing.

    • http://www.thehappymd.com/ Dike Drummond MD

      Yes azmed … we all remember being abused as medical students. Some attendings and residents were more abusive than others and thought it was their right to see just how much we could take. I am hoping that is “old school” and that some things have changed since I graduated.

      It is completely different for someone to be paid to perform a job description as an employee. The fact that they happen to be medical students is irrelevant and I am happy they have this opportunity to earn money and learn from veteran physicians at at the same time. It would have been nice for me to have had a way to make some spare cash and learn at the same time as a med student back in the day.

      My two cents,

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • azmd

        I certainly remember being abused at times when I was a medical student, but I certainly don’t recollect EVER feeling like the progress notes I wrote were “abuse.” Quite to the contrary, writing the notes was a valuable exercise in teaching me how to organize my clinical thinking and practice communicating “like a doctor.” I took a lot of pride in writing notes and it was nice to feel like it was a tangible contribution to the patient’s care.

  • http://www.thehappymd.com/ Dike Drummond MD

    Your last point is the most important one IMHO. Sounds like the scribe decreases the drain on you during work days significantly. That leaves you with more awareness and energy for your own self care needs, your family AND your patients. Win:Win:Win.

    What is that worth to you in dollars over the course of a year. If you made $240K without a scribe and were a wreck, teetering on the edge of burnout, stressed and unavailable for your family at the end of the shift OR you made $220K with a scribe and came home with a smile on your face from each shift. Is that worth it … before you answer … ask your wife and children first.

    I am waiting for the Neo braintap technology myself. Remember the movie “the Matrix” and that big pokey thing they would plug into the back of their heads while they were in the matrix. Plug me in when my shift starts … all my thoughts instantly transcribed … unplug me at the end of the shift. Someone is probably working on that right now.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • buzzkillersmith

      Bingo.

      People think they’ll be happy with just a little more money. Insanity– though a quite common form. My advice: docs should bag the fancy meals and hotels and cars and get the sleeping bag, some beans, a cigar and a bit of whiskey and the buddies or the family and hike into the Cascades or the Wallowas for a time. And they should get a scribe.

  • http://twitter.com/rboates Randall Oates, MD

    In-the-room scribes approach practicality in settings that are high volume, receive high levels of payment, or where the need to manage more structured data in real time is necessary.

    Real-time, but remote super-scribes (i.e. Medical Care Coordinators who not in the room) overcome just about all the limitations of in-the-room scribes. This is a very new approach that allows the docs to maintain control of the chart, but not have to do any charting other than review and sign off at the end of the encounter. The MCC is elsewhere and using a workstation with multiple charts and monitors, and so is not just being a scribe, but is doing much of the administrative tasks while the doc can monitor the actions on their iPad. Patients absolutely love this as it allows the doc to completely focus on them rather than the chart. Docs doing this either save 2-3 hours of daily scut work or see more patients (Usually a balance). The economic benefit can easily be in excess of 6 figures/annual with better documentation, better care, and greater satisfaction for all.

    Unfortunately, the user interfaces of the most common EMR systems, being designed to turn doctors into distracted data trolls, often are only able to gain a 3-5% improvement in efficiencies, and rarely more than 10%. In contrast, a properly designed system should give 10-20% improved capacity on day 1 at go-live, and can be in excess of 50% within 3-6 months. Certainly there are obstacles…. obsolete EHR systems and old habits die hard.

  • buzzkillersmith

    We dictate and the transcriptionist jockeys the EHR, even adding to the problem list. Jockeying the EHR yourself is the road to perdition.

    • http://twitter.com/rboates Randall Oates, MD

      Dictation is more often than not a waste of valuable physician time. It has a place for creating summary narratives, but most documentation can be created in real-time and just be reviewed and signed-off by the docs at the end of patient encounters. The only thing more wasteful than dictation is having the docs be distracted data trolls rather than being docs that are focused completely on their patients.

  • http://www.facebook.com/profile.php?id=639156794 facebook-639156794

    I have read all the comments and agree completely. Our dept started with a scribe program about a year ago. I used a scribe a few times, then struck out on my own and decided to do my own EMR documentation. I find that our scribes came in three flavors: barely adequate, good, and very good. Most were in the middle. And very few stayed more than 6 or 8 months before they go onto grad school or other opportunities. Their notes, although “wordy” , don’t always get to the point in “Doctor” speak, and the lists that are propagated are lengthy and make a clear picture of the patient obscure. Such is the nature of the new EMR, Unfortunately.without a scribe , I may stay a little longer at the end of my shift, but I feel that the note I generate is a much more accurate and medico-legally accurate one.