Scribes put humanity back into the practice of medicine

In a recent posting Dr. Kaylan Baban mused about the ubiquity of scribes and some of the reasons behind this growing phenomenon. Among them were the usual suspects: increasing patient loads leading to decreased visit times with the provider, increasing non-clinical demands monopolizing time that would be better spent actually practicing medicine, and improved legibility of notes, which are now the patient’s property and are used for a number of things other than merely jogging the physician’s memory ahead of the next visit. These are all valid, but I think there’s more to it. I think that perhaps technology has gone too far.


Until recently most of us (and by “us” I’m referring to clinicians working in fast-paced environments like a busy ER) have embraced the technological advances that have made our diagnostic challenges easier and our therapeutic choices more robust. Ultrasound is replacing the stethoscope and its use is becoming the standard of care for certain invasive procedures. Bedside testing can give us lab results in minutes that we used to wait an hour or more to receive. CTs and MRIs have — and I’m a bit queasy about this — rendered certain elements of the physical exam almost irrelevant. Hooray for technology.

Then came the EMR. It was inevitable, really. Our handwritten notes had become the butt of stale jokes and even if they were more or less legible they were not easily portable. The various template solutions weren’t much better, given their checkbox nature and multiple pages. Plus the amount of documentation required in order to get paid became absurd. I mean, a full review of systems on a sick ER patient in order to get the government to reimburse you at an appropriate level 5? Even if the patient can’t speak?

Dictation was always a good solution. A reasonable chart in a reasonable amount of time. But dictations cost money. In the case of the busy ER that usually means money the hospital has to spend for something it views as the ER group’s problem. Since the hospital has to have an EMR system, and since there is a significant financial incentive for it to achieve meaningful use, our hospital partners would prefer we forego the telephone and stick to the computer.

Fine. We’re team players. So we gave it a shot, and guess what? A lot of us found it to be one technologic step too far. It made us realize we were allowing technology to come so completely between us and our patients that the encounter was bordering on robotic.

There is little in this world more personal or intimate than the doctor-patient relationship. That human interaction is why many of us chose the profession in the first place and is the source of much of the satisfaction we derive from our practice. Scribes allow us to focus on our patients. Completely. We can speak to them, lay our hands on them, and look them in the eye without doing simultaneous data entry, or wasting time between patients sitting at the computer. We can keep it personal.

I don’t care how fast you can type or how great you are at multitasking. Any time spent working on your chart is time you could be spending doing what you signed up for: practicing medicine. Besides, a well-trained scribe is going to produce a better chart than you can, in real time. It’s just the way it is.

So yes, the current iteration of EMR’s is dysfunctional and time consuming. They will inevitably get better. It doesn’t matter. Until we reach the point at which the entire treatment area is one giant computer, in which the doctor-patient interaction is recorded as it happens, we will still be faced with filling out a chart. We will still be wasting time and giving our patients less than they deserve.

Scribes put some humanity back into the practice of medicine. This is what health care providers are beginning to realize. This is why scribes are becoming mainstream. In the not-too-distant future many of us will wonder how we managed so long without them.

Jim Pagano is an emergency physician and chief medical officer, Precision Scribes.

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  • Ed

    “There is little in this world more personal or intimate than the doctor-patient relationship.”

    You expect us to sacrifice our privacy and dignity for your convenience, expediency, and profit! I’ll never knowingly permit a scribe to participate in my healthcare!

    • SarahJ89

      I loath scribes. It communicates clearly that the doctor is working in a factory assembly line with no time to actually do his/her job. I have no desire to have some total stranger in the room taking notes. No thanks. The whole thing is icky and unprofessional.

    • Kaya5255

      I’m with you, Ed!!!
      I am totally opposed to uninvited observers while I’m receiving care. I don’t care if it’s a student, intern, scribe, etc.
      I will be seen only by my provider.

  • NPPCP

    Wow, you are really pumped about this scribe thing!!! You should open your own company and make some dough! Oh wait……

  • SteveCaley

    Yup-per! The Matrix will see you now. Beep!

  • JR DNR

    I can’t possible understand how having a scribe in person in the ER is cheaper than dictation, where you have some off site transcribing the notes.

    • Daniel

      Scribing isn’t a career. I and nearly all of my former coworkers became ER scribes as part of our path to medical/PA/nursing school, and we are willing to accept minimum wage in exchange for the knowledge and the experience the jobs provides us. The lower comparative cost of our time makes up for the increased amount of our time that the physician pays for. Using a scribe also results in more charts meeting higher level billing requirements, meaning the physician makes more money. Based on the payment system of the physician group (RVUs vs volume vs hourly vs combination), spending less time on charting due to having a scribe can allow physicians to see more patients. These claims are supported by the billing data of the physician group for which I worked.

      -Former scribe (not with the author’s company) and current medical student

      • Jim Pagano, MD

        Thank you. The life span of a scribe is about 18 months or so. When I was applying to medical school it was common for pre-med’s to do volunteer work–either in a hospital, physician’s office, clinic, whatever, to get a better sense of what they were getting themselves into and to prove their motivation. I got a spot at UCSF and had it not been for the kindness of one of the oncology fellows my total ‘experience’ would have amounted to putting labels on test tubes. Scribing gives aspiring clinicians the sort of experience that was unimaginable back then, plus they get paid for it. Minimum wage, but more that they would get as a volunteer. Plus, there is growing evidence that having been a scribe prior to entering medical school gives the student an advantage over those who did not have this experience. The day may come, and fairly soon, when scribing becomes a prerequisite for medical school admission.

        • JR DNR

          Medical Students need to be taught that a patient is a vulnerable human being that needs protecting while going through a stressful situation (illness). This includes protecting their privacy, their modesty, their body integrity, their emotional well being, their mental health, and ensuring they are as well rested as they can be.

          This is the only way we will get down the rate of PTSD after a hospital stay. (http://www.medpagetoday.com/MeetingCoverage/ATS/45904).

          Instead, being a scribe or participating in shadowing teaches future medical students early on to disregard all those things and to put their learning experiences, the hospital’s financial needs, and the needs of the staff first.

          • Jim Pagano, MD

            I’m going to have to disagree with you about this. Medicine does not have to be a dehumanizing experience. It should, and can be, the exact opposite. Yes, we have an advantage. We’re supposed to have an advantage. We are doctors and patients come to us because they believe we know more about their health issues than they do and that we can help them. It is up to us as physicians to communicate with them in an effective manner. It is our responsibility to put them at ease and to engender trust. And of course it is our job to respect their dignity, and to whatever extent possible, their privacy. I say this in this way because as you probably know ‘privacy’ in a busy ER has a different look than it does in a doctor’s office.

            Scribes allow the doctor to focus on the patient. This is where some of the humanity gets put back into the encounter. A well-trained scribe knows more about HIPPA than you can imagine. As the CMO of a scribe company it is my job to ensure that these young, future professionals get pointed in the right direction. Ethics, respect for patients, and professionalism are things I stress.

            I’m sure you did a residency, and I’m sure that it was similar to most–making rounds with the team, barging into patient rooms en masse to observe, discuss, poke and prod. We did this in the name of education. The patients were, by and large, good sports. They knew they were in a teaching hospital and allowed themselves to be on the teaching service.

            Clearly, you have retained a deep regard for the welfare of patients despite that experience. I believe I have as well, and I do my best to ensure that our scribes cultivate the same priorities.

          • JR DNR

            I imagine the patient coming in for a sore throat doesn’t care about a scribe.

            Unless they are there because they have been engaging in behaviors that lead them to believe they may have an STD in their throat.

            “Privacy” means no one – including a scribe – knowing things they don’t need to know.

          • Ed

            Scribes, shadows, chaperones, techs, and assistants, all invariably claiming we’re professionals too, most likely just high school graduates, are turning the exorbitantly expensive healthcare that we pay for, into a spectator sport; you folks have obviously lost your collective mind, soul, and humanity.

        • Ed

          Tell me why patients should give a damn about the career aspirations of high school and college students? Just the kind of folks we want present for our pelvic and prostate exams!

        • Jim Pagano, MD

          There seems to be some misunderstanding about who scribes are and why they would want to do this job. I’ve written a post on our company blog that goes into some detail for anyone who is interested. You can find it at precisionscribes.com, blog

      • JR DNR

        I think that medicine is already a dehumanizing process and focus needs to be made to not just serve a patient’s medical needs, but to protect their emotional and mental well being.

        As much as we want patients and providers to act as partners, there is still inequality. The provider has both medical knowledge and power (to order tests, provide medications, do procedures). The patient is at the doctor’s mercy, especially in an emergency or hospital setting.

        Take a patient who is nervous, uncomfortable, or scared, and add in a scribe. You’ve just made their experience more humiliating and dehumanizing.

      • Kaya5255

        And how many times did customers demand that you leave??

        • Daniel

          5 times, out of approximately 2,500 patient encounters in my 2 years of scribing. Of those, 4 were drug user, presenting for complaints related to their drug use, who seemed to believe that I was somehow affiliated with law enforcement. The 5th was a rape victim, who would not allow ANY male staff into the exam room. I would say there were an additional 20-30 female patients who were initially uncomfortable because the physician forgot to explain that I would not be present during their pelvic exam.

          Many patients actually enjoyed my presence. I would like to imagine that being a skinny guy wearing baggy scrubs (downside of being 6’5″) made me seem more approachable than a physician in a white coat, and patients/family would often engage me in small talk during procedures or examination. Older patients specifically enjoyed the idea of me working as a scribe as a way to learn more about the the medical profession. If anything, these experiences would indicate to me that having a scribe in the room made the experience of being in the ED less stressful, rather than more.

  • John C. Key MD

    I just don’t see it…if scribes are necessary to current care, then we need to review and revise what we are doing. Everyone now knows that the EMR really doesn’t do much for patient care–it just provides a way for management to catalog and direct clinical behavior. Scribes are just something that add to the cost picture. Admittedly I am a very good typist (or keyboarder) and some may not be, but to me the use of a scribe just buoys the idea of an arrogant physician who can’t be bothered with the small details and is too high and mighty to record things on his own. [Full disclosure: I am a fan of DPC and an unrelenting foe of the medical-industrial complex].

  • guest

    Or you can use copy and paste function. Templates with long PE and ROS. Correct a few details for each individual patient. Under MDM list your diagnoses, mention you personally reviewed the films, spoke to interpreting doctor. One line for plan, mention high risk or severe in that line. It is completely useless for communication with other docs but perfect for billing. Talk about illegible. If I need to learn about a new patient I would take a note written through a scribe any time. This way as strange as it may seem, some humanity is preserved in this business.

  • DeceasedMD

    very strange indeed. It seems that everyone is profiting from the MIC except somehow the actual doctors and nurses who do the work.

    • SarahJ89

      And the patients. None of this benefits us much.

      • DeceasedMD

        so true!!!

        • Jim Pagano, MD

          Actually, not so true. Doctors using scribes see an increase in productivity, often exceeding the cost of the scribes. Patients seen by doctors using scribes have more uninterrupted face time with the doctor and have expressed appreciation for this. Plus, the increase in productivity translates to decreased waiting times in places like busy ER’s and reduces the percentage of patients leaving without being seen, thereby improving patient satisfaction and reducing liability risk. Not a bad investment.

          • DeceasedMD

            How did we survive prior to EHR’s and scribes? scribes may have a use probably because EHR’s are so laborious. But all of these “efficiencies” are sucking the life out of medicine.

          • Jim Pagano, MD

            I, too, miss the days before the EMR, the relentless fixation on metrics, and the other de-provements we’ve been forced to accept. But I don’t think those days are coming back, at least not in what’s left of my career lifetime. Scribes are a way to mitigate some of this by getting you away from the computer and back at the bedside.

          • Ed

            I’ll gladly sacrifice face and wait time to maintain some measure of privacy and dignity. Your alternative is to bare our bodies and souls to high school and college students; not happening!

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

    So let me see if I understand this.
    We introduce computers into every aspect of practicing medicine with the hope that computers will make the entire business more efficient and improve quality of care.
    As it turns out, we observe that computers in their current form are at the very least hindering efficiency with no indication that quality is improved.
    We then introduce scribes to counteract the effects of computers.

    The net difference is that we can now collect discrete data elements, as opposed to the narrative structure of dictation, so we can better measure the effects of the computer.
    We continue to pay for the computers, and now we also pay for scribe services, which when added together far surpass the costs of old fashioned dictation.
    Since both computers and scribes are now additional fixed costs, reducing or containing costs of health care means that we have to find savings somewhere else.
    We then proceed to be surprised that people are supposed to be content with less health care, and doctors should accept less pay for their services.

    Next step is to develop and pay for a cloaking device to make scribes invisible in the exam room…. Why not? Makes as much sense as anything else we seem to be doing lately.

    • Jim Pagano, MD

      I empathize with what you’re saying. I’ve been in practice a long time and I’ve seen a number of ‘improvements’ in the delivery of care that have, in fact, been significant de-provements. The EMR is being forced on us. Scribes are a way to minimize the negative impact. As for the cloaking device, the large majority of patients are either oblivious to the scribe or grateful that the doctor can pay some undivided attention to them.

      • LeoHolmMD

        Have you considered remote scribing? I think that may ease some of the concerns people have about another person lurking in the room. It would return to the transcriptionist model in place previously. You would lose real time data entry, but that isn’t really happening anyway.
        On a previous discussion, I mentioned hybridizing the scribe roll to include billing and coding as well…a sort of super scribe. Thoughts?

        • buzzkillerjsmith

          Yup.

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

          Too efficient….

    • doc99

      Scribes are the result of poor judgement by Medicine’s Pharisees. If EMR’s were a new drug, they’d have been rejected by the FDA a long time ago

      Who are the bigger fools- the fools or the fools who follow them?

  • EmilyAnon

    Do your scribes present in street clothes or do they wear white lab coats to blend in with real clinicians?

    • Jim Pagano, MD

      Our scribes wear scrubs that identify them as such. No lab coats. We advise the clinicians to introduce them to the patient at the beginning of the clinical encounter.

      • Ed

        And when the patient politely declines or clearly indicates their uncomfortable with a scribe, what do you do then?

        • Jim Pagano, MD

          We ask the scribe to step out of the exam room. The clinician can then give a verbal report of the encounter afterward for charting purposes. We do not insist a scribe be present if the patient declines.

    • buzzkillerjsmith

      Beanies with propellers and those boongy eyes that pop out–the ones you can buy at the hobby shop.

      • EmilyAnon

        But that would be impersonating a doctor. A first-degree misdemeanor in my state.

        • buzzkillerjsmith

          Point for Emily! Nicely done.

          • EmilyAnon

            Thanks, Dr. Buzz, I try to keep on top of things.

  • A Banterings

    “There is little in this world more personal or intimate than the doctor-patient relationship.”

    The use of scribes is like a married couple bringing a 3rd person into the bedroom: In some couples, both are OK with it. In most couples one is for it (because they are the one getting something out of it) and the other is against it because they feel that it is an invasion of their privacy.

    Does this clear it up for those of you who are for it?

  • JR DNR

    I found statistics that one transcriptionist can cover four doctors, which means paying one transcriptionist vs four scribes.

    And as a patient, I don’t want any unnecessary people in the room. I certainly don’t tell my doctor’s medical assistant everything.

    I actually know that my doctor’s EMR has a section his staff can’t see. I appreciate that.

  • Ed

    “Dear” Jim,
    are you actually claiming that a scribe will improve the survival odds of your
    patients? If so, why weren’t you using scribes years ago? You’re not actually
    typing (distracted) at the keyboard during a real emergency are you? Be honest
    and admit you consider yourself above the drudgery of charting electronically
    and it’s a great opportunity to make a buck, while doing exactly zero to
    improve patient outcomes while adding to the already exorbitant fees this
    country pays for mediocre medical care.

  • buzzkillerjsmith

    Go back to transcriptionists. We have one that is very good. I even dictate the code and she puts it in. I have to put the scripts and lab tests into the EHR but am pretty quick at it.

    I agree with the author that EHRs are an absolute disaster for docs and that scribes would help a bit. But transcriptionists are a solution that works.

    Those poor souls that work in CorpMed probably don’t have the option but those still in doc-owned groups often do.

    • Jim Pagano, MD

      If by CorpMed you mean hospital-based, you’re right. ER doctors are pretty much captives of the hospitals and hospital corporations with which they contract. This is true if you are in a single-hospital democratic group or working for a large, multi-hospital ER contracting company. Hospitals are being forced to adopt the EMR nationwide, and the meaningful use bonuses will be kicking in soon. Because we are ‘captives’ we are expected to be leaders in use of the EMR. Most hospital CEO’s I’ve known are not happy about having to pay for an EMR system and also for dictations.

  • Ed

    Did you or the physician specifically solicit informed consent, clearly explaining your role, prior to the two of you entering the exam room? It’s much more difficult for patients to reject ancillary staff, in the physician’s presence, when their actually in the room. You know, that perceived paternalistic power differential that providers use to their advantage, instead of practicing ethical medicine; it’s called an ambush for a reason!

  • LeoHolmMD

    The data mongers have to learn the same lesson over and over. Without the appropriate intelligence (AI) examining the data in a meaningful way, storage and collection efforts are squandered. It’s very clear to me now: data becomes sewage, then becomes opiate. The EMR is your new TV. Like it on Facebook!

  • drval

    “Besides, a well-trained scribe is going to produce a better chart than you can, in real time. It’s just the way it is.” I completely disagree with this. How can a scribe possibly come up with an assessment and plan that is better than the MD? Perhaps a scribe can get the coding and billing right, but in terms of the most important part of a note – communicating the clinical reasoning behind the work up, likely ddx, and planned next steps… scribes will be totally lost. Unless… you’re not documenting any of that because you’re using notes for billing only. Which is its own travesty. :-(

    • Jim Pagano, MD

      There is a learning curve involved when working with a scribe. The clinician has to learn to think out loud so that the cognitive elements of the evaluation can then be properly documented by the scribe. It takes a couple of shifts for most doctors to get this down pat. Scribes don’t generally enter billing codes. They document what was said and done and the coders in the billing company then assign a level based on that information. Scribes are, for the most part, very bright, eager, and interested in careers in health care. It is important to them to ‘get it right’.

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

        So you are essentially dictating in real time…. Why not wear a microphone and have transcriptionists in medical records do the scribing and the coding like Dr. Holm suggested? Wouldn’t it be more efficient for the hospital, more flexible for you, and less intrusive for the patient that way?

        • Jim Pagano, MD

          The microphone is fine but the chart is not being created in real time and the process is essentially a dictation service. I have no problem with dictating my charts but as pressure to use the EMR rises ways to incorporate it in a minimally disruptive way, like using scribes, become important.
          The other option is tech wearables that transmit a recorded image of the encounter to someone sitting at a computer in some remote spot who then does the data entry. This has a certain tech-appeal but is no less intrusive than having a scribe in the room. At least with a scribe you know who’s there, and there are no images of your history and physical being transmitted over the internet.

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

            I’m sorry, but I am not sure I understand. Why would the scribe need images of the encounter? Do they document more than just what you (or the patient) say out loud?
            The microphone, by the way, could allow real time charting if you had a pool of remote scribes that get activated once the visit starts…. I’m pretty sure someone has a service like that going, using the iPad microphone…. Don’t think they do coding or billing though.

  • LeoHolmMD

    I was wondering about GoogleGlass. I think that would still raise concers for those patients sensative to outside realtime observers. A good idea at least.

  • Jim Pagano, MD

    The high acceptance rates are similar, though a tad less, than with scribes. It shows that patients are generally tolerant of any innovation that allows the doctor to focus on them. The concerns about privacy expressed in some of the comments are not supported by experience with these modalities. My personal worry with wearables is having to send the images over the internet.

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

      That, and also (as I said below), why would the remote scribe need to look at videos of the exam?
      Furthermore, when the EMR resides in the eye of the physician, how do you have the patient share the experience?
      Wouldn’t it be nicer to have a screen somewhere (even a tablet) that both parties can see? And if we can summon “Brandon’s labs” on the Glass with a short sentence, surely we can summon them on a screen that the patient can also see, no?
      It just doesn’t add up for me…. maybe I’m missing something.

      • EmilyAnon

        “That, and also (as I said below), why would the remote scribe need to look at videos of the exam?”

        I too would like to know why the scribe/transcriptionist has to view the exam, either remotely or in the room. Are their visual observations entered into the medical record?

    • Dennis Yun

      The issues of security over the internet are definitely a concern. However, these concerns have been around since transcription services have been utilizing the internet to transmit information. I would suspect that these companies and remote scribing companies would not be viable (and would be subject to massive HIPAA violations/fines) if their security infrastructures were not up to par with current regulations/standards.

      • Jim Pagano, MD

        HIPPA compliance is one of the first things touted by all vendors of wearables, and of every other company or agency through which patient information flows. Web security being what it is, or isn’t, the risk remains of information getting hijacked, however small.
        As for why images are needed, they probably aren’t, but as they say a picture is worth a thousand words. Certain physical findings and certain procedures are easier to document if a visual image accompanies the verbal description. A scribe in the room, introduced to and accepted by the patient, allows the information gleaned to stay in the room.

  • EmilyAnon

    You might be confusing patient acceptance with ignorance, apathy or blind trust. Also fear of angering the physician if they question something. Would you have a problem if the patient came in wearing google glass?

    • Dennis Yun

      I agree that these may be confused, but I do my best to educate my patients about why I am utilizing the technology. If the patient has any issues with it, then I immediately turn it off and return it to my office. I personally would not have a problem with the patient wearing a unit as I have nothing to hide from my patients and I do not fear that any of my words/actions in the exam room would be construed as misconduct. Perhaps a not-so-scrupulous provider would not share the same perspective.

      • Ed

        Help me understand why exactly you’re recording (video) patient encounters in the exam room?

  • JR DNR

    Can I recommend you read the current Patient Modesty thread at:

    http://bioethicsdiscussion.blogspot.com/

    It seems that most doctors are completely unaware that many patients are uncomfortable removing their clothing in front of medical providers, among other things. Patients rarely ever speak up even when it bothers them.

    I would suggest that many patients are uncomfortable with recording devices but are unwilling to speak up to you. They worry they don’t really have a choice, that you’ll treat them differently, that you’ll with hold care, that you’ll judge them, that you’ll fire them as a patient…

  • meyati

    I wonder if my PCPs-recent past and present would have treated me better, if a scribe had been around? Perhaps a message to the hospital on my EHR would have been written or phrased better, so I would have been released with antibiotics on a Friday.

    Maybe my current PCP would lie less.

    The last time I was at the Urgent Care, the man ahead of me asked if he could use the Urgent Care as primary, as his PCP was awful-and he always ended up at UC or the ER after a PCP visit. It’s at the point, where UC and ER no longer advise you to have a follow up with your PCP, but come back to them. It’s worth it to wait 5 hours in an UC or ER to get real care. I don’t ever want to see my PCP again, but I have to for TSH.

  • Kaya5255

    I never allow anyone other then my provider in the exam room.
    I do not permit medical students, nursing students, or any other type of student in the exam room. I will not even speak to them. Now SCRIBES??? Have you taken leave of your senses?
    These unwelcome intruders violate my privacy.
    When someone other then my provider enters the room I always ask who the person is and what they’re doing there. If I’m not satisified with the response…out they go!

    • Jim Pagano, MD

      Fortunately for every physician, nurse, nurse practitioner, and physician assistant not everyone feels as you do. An essential part of all our training is the participation in the care of patients under the supervision of an attending physician. If you appreciate the care you receive from your doctor now, it’s in large part due to the access he or she had to real patients while in training.

      • Kaya5255

        I’m quite sure that there are thousands of people who do not mind the intrusion of students, scribes and others into their private lives and gladly volunteer to be training aids. I am not one of them.
        It is called personal preference, something the medical profession chooses to disregard. I have a female physician because I don’t want a male. I do not allow students because I am not a teaching dummy.
        I refuse to allow unlicensed personnel near me. That is my choice and fortunately New York State upholds the consumers rights to make that decision.

      • Ed

        What other industry in the USA expects, absent true informed consent, to devote personal resources (their body), to the training of a new generation of anything, for free? Just another left over 19th century paternalistic practice long overdue change!

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