Do medical scribes threaten patient privacy?

Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance. There is no accepted definition of what scribes do or what their background or training should be. There is no mechanism for licensure of them in any state. They are poorly defined medical assistants. The field is in its infancy and its ultimate role in our health care system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry. This may or may not involve being present for the history and physical exam. Most commonly they are physically present in the room and witness the entire encounter. The need they fill is a function of our ever increasing mandates for electronic medical records (EMR). Before EMRs, the use of data processors in examining rooms was quite rare. Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all. Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized. The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal. Some advertisements require applicants to have a high school diploma or a year or two of college. Many make no mention of education at all. Some commercial sites train the scribe for a period varying from a few weeks to months. At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student. This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications. The majority of practices will not have access to premed or med students. The scribes are mostly young and it is likely that few will choose this as a permanent career. Thus they constantly have to train new ones. The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr. The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry. It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice. Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with. The dangers to patient privacy are clear but not often emphasized. How much of a concern this is depends on the practice. My ophthalmologist uses them without difficulty. Few would object to an assistant hearing your ophthalmological history.

But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant. A few have the assistant outside the room for this perhaps making the patient more comfortable. The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable. One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document. This took place in an academic setting with medical students used as scribes. The majority of the scribes were in fact men. The one female urologist in the practice with a predominately female following refused to be part of the study. I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background. The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice. The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy. But in emergency settings patients are less likely to be concerned about their privacy.

The accuracy of scribes has not been studied to my knowledge. The results would depend greatly on the background and training of the personnel. But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice. The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use. If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy. I don’t see how scribes without a medical background could ever be competent to understand a general medical history. It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes. This would also permit a far greater feeling of patient privacy. Patients have always understood that their medical records may be processed for administrative purposes.

The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient. They should not be used as chaperones or multipurpose medical assistants without further special training. In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves. There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries. This makes it increasingly impossible for solo physicians and small groups to stay in practice.

Joel Sherman is a cardiologist who blogs at Patient Modesty & Privacy Concerns.

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  • John C. Key MD

    The only two reasons I can think of to have a scribe are (1) arrogance and (2) laziness. Most folks of working age know their way around a
    QWERTY keyboard well enough to do it themselves; if not, there’s always Dragon or some other software that would pay for itself much more quickly than a scribe. Makes no sense to me.

    • Frank Lehman

      I pretty much agree with Key. With handwritten records the doctor had to spend a substantial amount of time writing things down with a pen, and with electronic records the doctor has to spend a substantial amount of time entering information with a device such as a keyboard. What is the difference?

      • buzzkillerjsmith

        Handwritten notes are often lousy. Dictated notes work pretty well and are a lot faster than typing and they give better notes.

        It would be instructive for non-docs to follow us around a bit. Univ. of WA med students follow me around, and, based on the fact that very few of them go into primary care, I surmise that they are mortified by my basically chaotic job. And UW is often considered the best primary care med school in the country.

        Many docs don’t have time during the day to take a bathroom break. 240 seconds in the bathroom means you go home 240 seconds later.

        If you can save 240 seconds per pt on documenting and you see 25 pts per day, well, you can do the math.

    • Kristy Sokoloski

      I agree with Dr. Key also which further backs up my thought that I asked about. My relative’s previous PCP when he was part of the clinic that we go to used a scribe several times, and even used Dragon software. I know he was not that thrilled with the software. My doctor has sometimes used his MA as a scribe but he is capable of typing the information for himself. Same with my rheumatologist, he types in his own notes.

    • LeoHolmMD

      Dragon is not that great. Order entry, and just using the EMR is in general, obnoxious. Scribes are a good way to increase face time and productivity.

    • Ava Marie Wensko George

      Our clinic physicians are under so much pressure to see a high volume of patients per day. I can assure you that they are neither arrogant or lazy. Dragon takes time to train and is very inefficient as well as inaccurate. Physicians would be spending more time trying to make a machine do what a very well educated workforce can – Hire a medical transcriptionist as your scribe. They are already trained.

      • Patient Kit

        I agree. I don’t see what the perceived value of a scribe instead of a transcriptionist is. Why can’t docs continue to audio record their notes and have a transcriptionist enter those notes into the EMR? What am I missing re what added value a scribe provides?

        • LeoHolmMD

          The demand for real time data entry and the current nature of data entry. It is no longer about getting thoughts onto paper. It is about clicking the right boxes. Hundreds and hundreds of clicks. In the traditional sense, I could see transcriptionists becoming extinct. It is unfortunate, because they are smart and insightful people. This is about harmonizing complex data entry. Imagine if I asked you how your day was, and all you could do is answer with emoticons…but there are thousands and thousands of them. They are not organized how you would think about them. The ones you need are not available. If you want to expand on one, you have to open a text box and free text in the nuances. You can see how this would make a relationship impossible. Welcome to EMR. This is why your doctor needs help.

    • buzzkillerjsmith

      Dragon is not that great. It slows me down much of the time but is OK for some cases. Typing is even slower. What works for us is a transcriptionist who knows how to jockey the EHR. We then look the note over and make changes as needed.

      Most of the time I don’t even have to look at the computer in the exam room. I do orders and scripts from the one in my office.

  • EmilyAnon

    It’s doubtful that the scribe would be identified as such when they enter the room with the doctor. They would be wearing a lab coat and ID tag looking very much like a nurse or clinical asistant, not the lay person they most likely are. The patient is trusting and would probably be too polite to question.

    • Lisa

      My doctors have always introduced any one who comes into the room with them and their function.

    • T H

      “Clinical assistant.”

      Funny choice of words there, because that is EXACTLY what a scribe is.

      • Ed

        Your definition, not mine. How about recorder/observer and non-professional at that?

        • T H

          “Professional” definition:
          noun, (of a person) engaged in a specified activity as one’s main paid occupation rather than as a pastime.

          At the least, they are trained as Medical Assistants. Many are paramedics or EMTs. I even have one on staff who is an MD waiting to go to residency. AND they get several weeks of training to actually be a scribe.

          This point you are attempting to make here, sir, is flat out wrong.

          • Ed

            T H, I appreciate your respectful discourse on this issue but we’ll just have to agree to disagree on the definition of a professional. For what it’s worth, here is my definition:

            A true professional is someone with an advanced degree, subject to strict codes of conduct and rigorous ethical and moral obligations, agreed upon and maintained through widely recognized professional organizations, and subject to disciplinary actions through state and/or federal regulatory oversight.

            Physicians certainly meet those requirements as I believe I do (airline pilot). A high school graduate (or equivalent) completing vocational training, is no more a professional than car mechanics and beauticians.

            While I agree your scribes are certainly better trained than the minimum requirements cited by Dr Sherman in this article, even you must agree that the average scribe patients encounter will likely not equal the qualifications you cite.

            Patients will be expected, absent informed consent, to bare their body and soul to medical professionals and their non-professional entourage. Their trust and faith is repaid by these unethical and unprofessional practices for expediency and profit alone; not my healthcare!

  • Ed

    I think it’s patronizing and paternalistic for any provider (physician, PA, NP, nurse) to show up in a physician or hospital exam room with a third party (student, scribe, shadow, or chaperon), whether they’re introduced correctly or not, absent specific informed consent obtained in advance. This tactic, otherwise known as an ambush, takes advantage of the perceived power differential between providers and patients because most folks simply assume they have no choice in the matter. And the trite and often repeated “we’re all professionals here” excuse is BS. While they may work with professionals, high school graduates or college students who’ve completed some sort of vocational training are anything but. Scribes and shadows rank right up there with receptionists and my only medical interaction with them will be a polite but firm no.

  • Kristy Sokoloski

    I am glad to see this article because I have been wondering a lot about medical scribes. But I have been wondering about them for a different reason. The reason has to do with the job of those that were medical transcriptionists. Wouldn’t all these years of having them type up reports that go in to a patient chart, or letters from a Primary Care Physician to a specialist that the patient is being referred to or vice versa also be considered an invasion of privacy and an affect on the doctor/patient relationship in other ways that could be problematic? And if I am not mistaken the people who have done this job don’t exactly have medical training either. What about the medical secretaries (now called medical administrative assistants)? Wouldn’t this apply to them also? The reason I also ask this about the medical secretaries is because sometimes they are having to take information that needs to be put in message form when it comes to patients needing help from their doctors. And when one schedules an appointment the secretary will ask what the reason is for why they are coming to see the doctor so that they know how to schedule appropriately.

    • Ava Marie Wensko George

      Kristy, you would be very much mistaken. Medical transcriptionists in a level 1 trauma center teaching hospital have the same education as a 3rd year medical student. A medical secretary is just a glorified typist. A medical transcriptionist’s educational background includes Medical Terminology, Anatomy and physiology, pathophysiology, pharmacology, biology, disease and disease process, and is usually a graduate of an accredited school. Many of them are certified in their profession. They are professionally ready to transition from behind the keyboard to the physician office, ER, or other ancillary care center. I wouldn’t disregard their efficiency or professionalism.

      • EmilyAnon

        A third year medical student most likely has an undergraduate degree plus 2 years of post graduate training in a medical school under his belt. How can you compare this with a medical transcriptionist who, according to the Bureau of Labor Statistics, only needs high school plus non specified vocational training.

        • Kristy Sokoloski

          Emily, that is correct. The two can’t be compared. This backs up my point about how it is more like a vocational certificate.

      • Kristy Sokoloski

        Not all hospitals are the same. And the fact that a Medical transcriptionist is typing up information for a report on a patient regardless of how much training that Medical Transcriptionist has could easily be an invasion of privacy just like having a 3rd year Medical student in the room if the patient does not want that Medical student in the room with them and their doctor. Also, Medical Transcription has changed so much in the way that they get their training that it is like a vocational certificate and it is not even remotely close to the kind of training someone would get in Medical or Nursing School. Interesting thought though.

      • buzzkillerjsmith

        I like transcriptionists, but I think you swung and missed on the education thing. I don’t think ours took courses differential equations and quantum mechanics at the University of California. But I guess I could be wrong about that.

  • Kristy Sokoloski

    A handwritten note can take about as much time to get put in the chart as it does to type a note in the chart. Also, with paper charts they are having to flip through the other pages just like one is having to scroll through the various screens in order to get the information.

    The two doctors I mentioned in my post to Dr. Key about being able to type their own notes, they have also been able to type and talk to me at the same time. Same with my Pain Management doctor and my allergist.

    Each doctor must find what works best for them. But then again no system is exactly perfect either.

    • 1775concord

      Much harder to scroll through an EMR versus flipping through organized (by time/date of visit, lab reports, outside letters, radiology report, PT reports) paper charts. And electronic records just reek of non-privacy concerns.

      • Lisa

        It takes time to organize paper charts, but then It takes time to maintain any record keeping system.
        And I think there are privacy concerns with either electronic records and paper records.

        • Kristy Sokoloski

          Lisa, you are spot on when you say about that there are privacy concerns regardless of the system that is used to maintain the records.

      • Kristy Sokoloski

        Interesting, because when I would go through the charts to do part of my job while on externship for my Medical Assisting program in 2011 I found it harder to work through the paper charts. I noticed that my doctors also had some issues especially as my charts got thicker and thicker. As for the non-privacy concerns, couldn’t the same have been said of paper charts? Privacy can easily be breeched because of a paper chart being left open on the counter. I know because I saw it happen at one of my doctor’s offices that a chart was left open. I could see the medication sheet of the other patient. I made sure to tell my doctor that someone had left that chart open for all to see. And my thought was “hmm, if I can see this then other patients that walk by could easily look at that chart.

        • 1775concord

          I would take notes and dictate the note after the visit. Office notes were in chronological order. Hospital notes separate. Lab reports separate. PT/OT separate. X-ray reports separate. Not that the note is handwritten, but that the interaction is dr-pt only.
          EHR is, and will be, notoriously insecure with internet lack of security. As the govt. Or Mastercard. Or Target.
          Of course a chart should not be left open on the counter. Obvious breach of security and office protocol, sidelight to this discussion. So who in your dr’s office left the chart open?
          What “issues” did your drs have? I don’t understand.
          In no way do I want to scroll through a 100 page chart.

  • Kristy Sokoloski

    I agree about that the working more as a team should apply to that of consultation and procedures. However, wasn’t it written about here in previous entries that the H&P is not as valued in the Medical Schools as they once were?

    • 1775concord

      Oh, let us hope not. Not when I went to medical school, not when I taught medical students, interns, and residents. Though many neurology residents would order a CAT scan before doing a good neurological exam. The newer, continually improving tests are great, but cannot substitute for a physician doing a complete exam. It’s sloppy medicine. Those tests, which usually require a “Mother may I” from the insurance company, are expensive, too. Physical exams are very valued.

      • Kristy Sokoloski

        I agree that Physical exams are very valued because that can so often help with the diagnosis but when I read (and I thought it was commented in a blog entry on here that stated this) that physical exam was becoming devalued that had me very concerned.

  • 1775concord

    A scribe is not a doctor and has no business in the doctor-patient relationship.
    Are insurance companies going to put a new billing code in to pay for scribes?

    • NewMexicoRam

      Do you really think so? They are “paid for” by allowing the doctor to see more patients.

    • Ava Marie Wensko George

      Transcriptionists are not either, but they are considered a very integral part of the team.

    • LeoHolmMD

      Are they going to notify you every time they troll your data? What is the code for that? How about following your pharmacy data? They can do that too. How do insurance companies pay for chronic disease managers to call you at home unsolicited? How do employers pay for wellness programs to troll your biometrics? Yes, let us finally get around to talking about patient privacy…over scribes. Jeez.

      • Lisa

        None of my doctors have ever used scribes, yet I have gotten calls from my insurance companies offering me the services of a nurse manager for my complex conditions (breast cancer, two hip replacements). I was furious because I was contacted repeatedly even though I said I didn’t see the need for those services – they contacted me after I was done with surgeries and active treatment.

        • buzzkillerjsmith

          Look at it from their point of view: If you don’t get unnecessary services, they don’t get paid for providing them.

          • EmilyAnon

            Buzz, you’re too funny. It’s obvious you’ve seen it all. Do you jest with you patients too? I’d’ look forward to your appointments.

          • Lisa

            Well, they could have contacted me shortly after my diagnosis and their services/advice might have been useful. Oh well. . . .I guess the moral of the story is if you are going to mine data, make sure the data is good . . .

  • PrimaryCareDoc

    I’m not on EMR yet, and I’m dreading the day we start, but I’ll never use a scribe. I’m too much of a control freak. I’m responsible for what goes into the chart, and I’m sure not trusting some college or med student to do it for me.

    • T H

      Never say never. When you go to EHR and suddenly your ability to move through the day is impaired by 50-70%… scribes will be seen as a godsend.

    • buzzkillerjsmith

      You could look over the note and make changes before signing off on it. That’s what I do when the transcriptionist puts the stuff into the EHR.

  • Ava Marie Wensko George

    If transcriptionists were transitioned over to the medical scribe area, you would not have a fear of HIPAA violations. The problem here is that a company came up with a “solution” and did not take the time to actually look at the workforce of people that are currently performing this role, but who are in another setting. I say hire a medical transcriptionist as a scribe and you will not have to worry about HIPAA violations or accuracy.

  • Patient Kit

    Right or wrong, I think a major underlying assumption about EMRs is that, in this day and age, most people are comfortable on computers and being able to type or keyboard is as common as being able to use a cell phone. I think there are problems with EMRs related to design and what purpose they are designed to serve and whether, when used badly, they create a wall between doc and patient. But I think it’s assumed that typing is faster than writing things out by hand and that most docs can keyboard as well as the general population.

    • LeoHolmMD

      It is the hunting and clicking. Even if your typing is superb, it’s the screen flips, menus and so forth. Bad design. Not all EMRs are equal. I assure you, dictation was as fast as it gets. And yes, my typing sucks.

  • JR

    I don’t want any guests at my appointments: No chaperones, no students, no scribes, no nobody.

    Have a doctor make fun of you with an uninvited guest at one of your appointments some time and you’ll feel the same way.

  • toolate

    Speak up. Hi Dr. X, I’m not comfortable with a scribe.

    Scenario 1: Dr. X: Oh, OK…will proceed without.

    Scenario 2: Dr. X refuses to part with scribe.

    Solution: find new dermatologist. Done.

    There is no way in hell I’d undress before a ‘scribe’. Period.

    • fatherhash

      would you undress in front of the doctor’s medical assistant?….if so, then they just need to change the title, haha.

      • EmilyAnon

        That’s right. Address a patient’s concern by mocking them. And then you scratch your head wondering why doctors are losing respect.

        • fatherhash

          not meant to be mocking….just to get some perspective. when i go to the doctor’s office, i know there will be others(other than just my doctor) that may listen to(and see) me. the “nurse” in/out of the room is just as much a “stranger” to me as a “scribe” would be

          • Ed

            “would you undress in front of the doctor’s medical assistant?”

            Generally no but it depends on the assistant, their qualifications, their purpose in being there, and ultimately how I benefit. There is a vast distinction between a scribe whose purpose is simply to record/observe and an assistant actually administering medical care.

          • fatherhash

            as i described to another post, an “assistant” of a male ob/gyn examining a patient is many times there JUST to observe(as a “chaperone” just in case of future complaints). so which is more useful?….the scribe actually documenting for the physician or the “chaperone” just observing?

        • fatherhash

          not meant to be mocking….just to get some perspective. when i go to the doctor’s office, i know there will be others(other than just my doctor) that may listen to(and see) me. the “nurse” in/out of the room is just as much a “stranger” to me as a “scribe” would be

  • toolate

    “I think it’s getting downright disrespectful the way patient’s are expected to accept all these accommodations which, in most cases, benefit the doctor. ”

    Oy. No matter how much we explain and explain how it’s corpmed that has crushed doctors into cogs and how we are trapped powerless and MISERABLE, our voice isn’t heard. It’s like talking to the wall. It’s all our fault, that’s what the public believes. I regret looking. Didn’t need that. Salt, wounds, all that. Just shoot me and be done with it.

    • Jean Oliver

      My apologies: I did not mean to doctor “bash” and I completely understand and sympathize with doctors’ angst over corpmed. I think it is doing both doctors and patients a disservice. However, since this article was about scribes I do believe that a doctor has the ultimate choice about who is in the exam room, EMR requirements or not. And that choice should be one that is jointly decided between the patient and doctor. Too many times we are not asked and ultimately feel that we have no choice. I sometimes feel that many doctors do not realize that patients have varying degrees of bodily modesty and adding additional personnel into the exam room makes the encounter all the more difficult, sometimes bordering on traumatic. Yes, there is an erosion of privacy but to me having to bare my body to numerous individuals of varying degrees of “professionalism” is unacceptable.

      • toolate

        I agree, it’s unacceptable. Stand up to insurance and hospitals and Medicare and tell them you want your privacy, and you want your doctor to not have to deal with impossible EMR, and you want him to be respected and have as much time to do his job as he needs. I’d never agree to a scribe in the room, not as a patient and certainly not as a doctor. No way. But as a patient you have to help by directing your anger towards the party in power and not the doctor who is held hostage by the threat that if he does ANYTHING ‘out of line’, he will be terminated, reported to the central data base and will never be able to work again. Doctors have no power. You as a patient have much more. I keep saying this but no one believes it, because it goes against the whole propaganda by all the forces that leech off the system, whose faces you don’t see, and they have billions to spend on convincing the public that we are the bad guys.

  • LeoHolmMD

    You are developing a lengthy “enemies” list of people who are allowed by law to “violate” your privacy:

    Your employer
    Your insurance company
    Wellness companies
    Insurance auditors
    HHS/CMS (Meaningful use and almost any other reason)(aka: the government)
    The armies of auditors working for CMS/HHS.
    Medical group compliance officers
    IT employees
    Essentially anyone who can claim to be “involved in your care”
    HIPAA protects all of these people.

    I am with you on privacy. Why put your foot down at the scribe? I agree that the patient should consent at all points. Getting “off the grid” is becoming a privilege. But it should not be.

    And BTW, when you go into anyplace with “patient centered” in the title, add community health workers,chronic disease managers and accreditation agencies to the list.

  • Kristy Sokoloski

    I agree with you about when you say about that trust by the patient in a doctor and the medical system begins with the eye to eye history taking and the understanding which is the laying on the hands” relating to the physical exam which like I told the other person that commented to my comment regarding this it concerned me a great deal that this kind of exam would be devalued. And it worried me a lot. Thank you for adding further to this.

  • Kristy Sokoloski

    I agree with Ed on this about who the team should consist of. It should be my doctor and I.

  • T H

    Naive statement. The team also consists of the front desk, the billing specialists, coders – both on the doctor’s side and the insurance side.

    • EmilyAnon

      Obviously all who work in a doctor’s office are a member of the doctor’s team in a broader sense, even housekeeping and mailroom people. I think the patients responding on this thread are concerned about which members of this team will be in the exam room. Hopefully you were just taking advantage of a “gotcha” moment with the term “team” and not suggesting that just because somebody is on payroll their duties include physical access to the patient during examination.

      • T H

        No, this is not a ‘gotcha’ and I’m not suggesting that the janitors and such are part of the issue.

        I AM however stating that anyone who sees the chart (or merely parts of the chart) is part of the team. They have access to the information gained during the physical exam AND they have much less context than the scribe who is present (though I routinely do ask my scribe to step out when I’m doing male and female exams).

        If a patient asks that my scribe step out of the room, I have the scribe do so, but there needs to be full knowledge that the scribes are often better record keepers than I am because they are typing or writing in real time. I do not do this so I can concentrate on listening to the patient, observing the patient, and also speak with family members present. In a busy ED or clinic, a scribe is an essential member of the team. Plus, my hospital hires EMTs, Paramedics, and MAs who are medically trained to be scribes: sometimes they recall things I do not.

        To state that this was a ‘gotcha’ statement implies to me that you have not thought the issue all the way through. Or if you have, that you discount the physician’s need for an additional aide in delivering medical care.

        • EmilyAnon

          Most patients are aware that that everybody and their uncle can read the doctor’s notes. This is more about all the extra people in the exam room when the patient is disrobed. You seem to “discount” this patient concern. Or maybe you just don’t care.

          • T H

            On the contrary, I am very much interested and concerned about patients’ comfort: I have been a patient, I am a patient, and I will be for the foreseeable future. 2 of my docs use scribes – one of the docs really, really NEEDS a scribe. Otherwise, he’s slow and his handwriting is the gold standard for ‘physician-terrible.’

            If someone does not want a scribe, I have the scribe step out. And I rarely have a scribe present for an exam that exposes sensitive areas (and only with permission).

            OTOH, I don’t make a big deal about the presence of a scribe. If I treat the scribe as a professional, which they are, and I treat the patient with empathy and my best effort and explain that the scribe is there for the patient’s benefit (which is absolutely true), things generally go fine for both patient and doctor.

          • EmilyAnon

            Thanks for elaborating on how you treat your patients. Otherwise, from reading the comments here I had visions of doctors using the same arguments with the patient if they objected to the scribe’s presence. Just for the record I have never had a doctor use a scribe with me. They either use a recording device or type quickly on a laptop. My hospital docs do their notes after the exam on a wall computer outside each room.

  • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, MD

    Why not a clip on microphone for the physician to input his/her comments as the history and physical exam proceeds? The spoken text is then immediately translated into written text by the same wonderful translation apps on everyone’s cell phone and the history and exam proceeds smoothly. As far as later review is concerned, the physician must take time later to do that for the same rationale that the physician must review and correct even the scribe’s work– for accuracy and completeness.
    With a spoken narration, the physician’s eyes are always directed to the patient and the patient gets to make corrections to the narration of history or importantly ask questions and thus be educated about points in the description of the physical exam findings. This technique will hardly cost an office or ER the price of a scribe and for the patient: privacy. ..Maurice.

  • T H

    It is only your perception that they manage their EHRs just fine.

    It is your right to refuse, but only ED physicians MUST care for you when you show up in their office/clinic/hospital.

  • T H

    I always try to introduce my scribe. When I do not, it is because there is sometimes literally no time (emergency intubation, cardiac arrest, etc.). If I’m going to discharge a person or talk over lab results with a patient, sometimes my scribe beats me to the next room: then they introduce themselves.

    And nothing stops you from asking “Who is this?”

    It isn’t an ethical dilemma. If my scribe isn’t introduced, it is because it is an oversight that is easily rectified. Oversights are not dilemmas: that implies I am deliberately keeping the information from you, which there is no reason to do.

  • T H

    No direct benefit? Indeed. So there must be a direct benefit to you for something to be useful.

    The direct benefit is that you are seen more quickly, the documentation is more thorough, and you are out of the clinic more quickly. If these are not direct benefits, what would you call them?

  • fatherhash

    excellent point….it seems that many that are against the scribes are looking at it only from their perspective as the patient with little regard for the other patients having to wait for the doctor to finish his/her own chart….all so that one person can have a little more privacy

  • JR

    Would you be willing to write EMR reviews?

    I’d really like to see reviews complete with screen shots – what’s good, what’s bad, what works, what is a time waster.

    It would benefit those shopping for EMRs as well as those designing or creating EMRs. Use social media to provoke some changes.

  • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, MD

    I was informed by one of my Patient Modesty thread visitors to my Bioethics Discussion Blog http://bioethicsdiscussion.blogspot.com/2014/04/patient-modesty-volume-65.html, after I mentioned a possible use of the physician’s voice input into EMR instead of typing using a scribe, to Google the combination. So I did and I finally wrote “voice recognition EMR” and I was amazed to find that this function is alive and well and as described seems to challenge any need of a scribe. So now I wonder who is overstating need and value: voice recognition companies or scribe providers. ..Maurice.

    • Joel Sherman MD

      I’d like to hear from providers who have actually used these systems. Are they ready for prime time? That is can they really be error free enough to avoid substantial corrections having to be made by the provider thereby undoing the reason for getting them in the first place? Most of what we see are ads by companies who lease scribes or who sell software. Medical societies such as the AMA need to evaluate the actual performance of these entities.

      • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, MD

        And added to such evaluations of the methods of EMR recording, the medical societies and of course also the government should consider in addition to the importance of statistical documentation, which may not have any immediate value to the patient, the added factors of patient autonomy and privacy. These direct and immediate interests of the patient should have equal consideration. ..Maurice.

  • fatherhash

    so you think that $20k goes to that one doctor you want the extra time from?

    good luck in continuing to find doctors so accommodating. keep in mind, the majority of doctors are not happy about needing/wanting(point of contention) scribes to begin with. with more regulations and mandates comes more burdens…more burdens that doctors have to deal with(sometimes with no better choices than doing things like getting scribes for the mandate of having to use EHR).

    i would assume that most doctors would love to go back to the times where scribes were not needed AND healthcare costs were less!

  • fatherhash

    i suppose it’s nice for you to have this option….women have had to suffer this invasion(in your view) to their “privacy and dignity” for a long time when they see their male ob/gyns. they’ve had to be subjected to these “chaperones” in the room that are there for the sole purpose of observing.

  • T H

    For some reason you are under the misapprehension that a scribe is unable to respect your privacy.

    And my job as a physician is to give you my best effort and medical advice. You are under no obligation to follow it, though the system can penalize me either professionally or financially when you do not.

    The medicine you seem to want went out the door with Marcus Welby.

  • T H

    No, not all physicians do. Neither do all patients care as deeply about the issue of scribes as you do.

    There are many way that modern medicine is not kind to either the patients or the physicians. Scribes = a necessary evil.

  • MynameisPT

    Scribes should never be introduced as assistant and most have no
    clinical training. Any physician allowing a scribe to assist in any
    medical procedure would be subject to disciplinary action by the
    state medical board including legal liability to the hospital or
    medical facility.

    Therefore scribes are NOT an assistant and should never be
    introduced as such. Fact is a scribe should never introduce or
    enter a patients room before the physician. Some posters state
    that a transcriptionist would best be served in this role and that
    rules of hipaa would not be violated. I have seen transcriptionists,
    nurses, physicians terminated for hipaa violations. Makes no
    difference on job classification, stupid is forever.

    Read AMA recommendations on chaperones and it appears that
    scribes are a direct contrast to AMA suggestions. In conclusion,
    scribes add another dimension to ever increasing healthcare costs
    and lack of patient privacy.

  • fatherhash

    yes, the vast majority in training are female, but there are still a significant number of practicing males. regardless, the coincidental decline of this being as much of a problem has nothing to do with the actual problem.

    and i am not asserting “payback” in any form….i’m trying to show some perspective. your wife’s ob/gyn is following a practice style that is essentially forbidden in residency training(and also is not very prudent). what would he do if a patient(or a few) for whatever reason(even disgruntled) complained of some sexual impropriety?

    but i truly am glad for you and your wife that you have found doctors that practice in line with your privacy views. i was merely trying to say that it is(and will be) becoming ever harder to find that…due to reasons that are mostly out of the doctors’ control.

  • fatherhash

    i actually agree with you on many fronts. i’m all for patients getting what they want and doctors respecting their wishes….but someone’s(likely the patient in the long run) gonna have to pay for it.

    i guess the difference in opinions is on what you/i feel is already paid for vs not. i tend to feel increased admin burdens placed by insurance companies that are not reimbursed(e.g. having to use EHRs) should be paid for.

    i assume that you feel that you’re premiums and copays already cover these costs….and from the insurance company’s perspective, they do. but what if next year, the insurance company places another burden upon the doctors’ offices without increasing the reimbursement?….and the year after?….and the year after? this is what has pretty much been happening….hence the frustration that doctors have been conveying.

    i’m computer savvy and have minimal problems with EHR(and have never used a scribe and have no intention to because my OCD )….but i know many older doctors that cannot move throughout the day without a scribe….maybe you feel that those “dinosaurs” should retire or maybe you feel they need to learn yet another skill or maybe you feel they just need to suck it up and do the extra work(insurance required EHR) for no pay. just saying that unfunded mandates have a cost.

  • Wannabmd

    So sorry for what happened to your son. It seems he was the victim of the “assistant training” which was actually just a chaparone. Can you imagine a 19 yr old girl getting her pap smear with a young male assistant looking on? This unethical treatment of males goes on and on. Another huge pet peeve of mine is the fact that a genital and rectal exam on a 19 yr old is a complete waste of time. So much time and money is wasted on these physicals for young healthy asymptomatic men, soldiers, athletes, etc. Not to mention the psychological implications of the common scenario you described above. It is just not right.

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