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.