To scribe or not to scribe? That is the question. [PODCAST]

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“I was working at an urgent treatment center, where a busy Saturday in January would be overwhelming. At one point, I hired a scribe. She was a bright young woman interested in medicine and some alacrity with computers. It was a pleasant change of pace for me.

She would accompany me into the exam room under instructions to remain unobtrusive and abide by HIPAA. I found that she could record the pertinent negatives and positives on the physical exam and the review of systems. She could record the assessment and plan as well.

I was then able to give the patient my full attention during their 15-minute visit. I could even maintain eye contact and have a conversation without the distraction of a computer screen demanding my attention. I could feel like a human being instead of a data entry clerk.”

Janet Tamaren is a family physician and author of Yankee Doctor in the Bible Belt: A Memoir. She can be reached at her self-titled site, Dr. Janet Tamaren, and on Twitter @jtamaren.

She shares her story and discusses her KevinMD article, “To scribe or not to scribe? That is the question.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today we welcome back to the show Janet Tamaren. She is a family physician and author of the book Yankee Doctor in the Bible Belt: A Memoir. We’re going to talk about her KevinMD article, “To scribe or not to scribe? That is the question.” Janet, welcome back to the show.

Janet Tamaren: Thank you.

Kevin Pho: So you’ve been on the show multiple times. For those interested in hearing Janet’s story, just go to KevinMD.com/podcast, click on the search icon in the upper right-hand corner, and search for Janet’s previous articles to hear about her story. But today, let’s jump right into your KevinMD article, “To scribe or not to scribe? That is the question.” For those who didn’t get a chance to read it, just walk my audience through it and share the story of why you decided to write it.

Janet Tamaren: Well, I’d been doctoring for 10 or 15 years, maybe longer, when suddenly the electronic medical records popped up on the scene, and that was quite a transition. I noticed when they first popped up that I could handle that transition pretty well. I was working in my own clinic in Kentucky, and I had a system that I got used to, where the nurse had input so much of the data. So when I came to the platform, came to the template, it wasn’t all that difficult to add the various components of the routine exam, the SOAP note, and most importantly the assessment and plan, so you could get, and a billing component, to get the patient out the door. There were some questions that were bothersome and repetitive, though.

Then I moved to Denver in 2013 and started working in urgent treatment centers, and their electronic medical record, I felt, was dreadful. I don’t know if all of the systems had evolved into this very picky, very picayune, very detailed, repetitive, and useless pointing and clicking, clicking on the computer screen while you’re talking to the patient. I don’t know if that was true throughout the country, but it certainly was in the system where I was working. It felt like they were adding more and more data points, and they were not to benefit the patient, not to benefit the doctor, certainly. It felt like we were answering some sort of call to record more and more data for some uber system that was collecting data across the country.

It might have been, and I suspect I’m not totally paranoid, that the health care systems could recoup more money if they documented that we asked the patient all sorts of questions that we intuitively knew about, like, are they dealing with abuse at home? But kind of document everything, and it’s becoming really cumbersome. In fact, when I was working in one of these urgent treatment centers here in Denver, I recorded how many clicks there were to get through the note. There were 92 clicks, and I did not get through the note during the time the patient was in the clinic.

I would write down or click in the salient points, the stuff I had to know: What did they look like, what did they say, what was the exam, what was pertinent about the exam, what my impression was, and, very importantly, what the plan was. So I’d get all that in there, and the follow-up, but the rest of it I couldn’t. There was no way on God’s earth I had time to do that during the 15 minutes I was allotted per patient in the urgent treatment center. On a busy day, you would spend five minutes with the patient and dash back to the office and start clicking, and that didn’t feel very good. So what you’d end up doing is staying late to finish the notes, and it would be an extra couple of hours late, because if you’ve seen 20 or 30 patients, that’s how it added up. Again, I timed that. It came down to 10 minutes per template in addition to the input I was doing during the patient visit.

Kevin Pho: Before we go further and talk about some of the solutions, paint us a little bit more of a picture. So you were in the urgent care center, and let’s say someone came in with a common complaint. It could be, say, a UTI or upper respiratory symptoms. Tell me about some of the inane questions that you feel the EMR would force you to put in when someone would just come in for a routine issue.

Janet Tamaren: There were all sorts of background issues. You had to know if there was a concern for domestic abuse, or how much they smoke, when it was already in the record. This was all stuff that was already in the record, and every time you had to go through and repeat it. Again, it felt like we were satisfying some governmentally induced data point that did not pertain to whether they had a cold or something more serious, and it was stuff that we already knew about the patient that we had to go ahead and document.

In the urgent treatment center, you didn’t know the patient, so you may not have known it, but I didn’t feel it was our purview in that setting to ask if they’d been sexually abused as a child. I’m not sure if it was that far afield, but there were all sorts of points they wanted to know. And you could see, when you got to the billing questions, they wanted to know all these details about exactly what kind of cold they had, or exactly some data points that weren’t necessary from a clinical point of view. Somehow I felt like I was adding to some giant pool of data that had no point.

Kevin Pho: So how did your experience with these electronic health records affect your joy of doctoring?

Janet Tamaren: The pressure, the time pressure to get through the visit, which became circumscribed because you were only allowed, I mean, it was such that you had maybe five or six minutes actually face to face with the patient, if you were that lucky. Then you had to scurry and input into the record as much as you could, enough to get them out the door, which I felt was a real insult to the patient.

My joy in doctoring has always consisted of talking to the patient and getting a feel for the patient. I’ve always enjoyed trying to puzzle out what’s wrong with them, which takes some time, because often patients, maybe not so much in urgent care, but certainly in my prior experience working in a rural health center, tell a story that seems to be going nowhere. They’re all over the map. It’s circumlocution. As you ask them what’s wrong, they’re just wandering through some long story. It takes a while to get to what really brought them in, or it takes a while to throw out all the other things they’re worried about, which they may have picked up from Google.com. They might be worried about cancer when they don’t; they have a skin rash. So you have to sort of get at what it is that really brought them in, and it can take a while to get there. It takes time to get to the kernel of whatever story the patient is telling, and if you didn’t have that time, it became very mechanical.

My concern about that is that the pressure is such that you are tempted to reach for the first thing that comes to mind. If they come in complaining, “I have sinus pressure, I have pressure,” and they point to their cheek or their forehead, you feel driven to say, “Sinusitis, thank you very much, see you in a couple of weeks.” Or maybe not “see you,” just “come back.” Or maybe you don’t say anything: “It ought to go away.” So it puts more pressure on you to grab the first thing they give you, the first nibble they give you that you can pin your diagnosis on, and send them out the door.

That is always my fear when I see a provider now, that they’re going to take the first thing and run with it, because the temptation is so strong, the time pressures are so strong, and it’s hard to get enough data to paint a larger picture than that. I think that is a temptation, especially in a fast-moving clinic like urgent care. We’re all told in training, “Don’t look for zebras, don’t jump to zebras.” But at the same time, you can’t jump to the most ordinary, most common explanation, because one in 10 times, it’s not going to work.

Kevin Pho: So to address this, in your story, you eventually did hire a scribe. Before going into that decision, just tell my audience what a scribe is, for those who aren’t familiar with that.

Janet Tamaren: Well, in my situation, I hired two young women, different young women, to just follow me around in the clinic room, trying to be unobtrusive. I went through the HIPAA stuff with them, so they knew that this was a sacred space and there was no repeating what we heard in there. Their mission was, whatever it was I would call out, and I would call out something pertinent, I would say, “I hear rough sounds in the posterior chest,” and they were to transmit that to the physical exam. I’d call out whatever I wanted to transmit to the physical exam, with the understanding that the rest of it looked pretty gosh damn benign.

Then I would get to the past medical history, and I’d call out whatever was pertinent there. I’d say, “Oh, so you’ve had breast biopsies a couple of times now, but that’s been taken care of, OK.” So the scribe would be writing down whatever I called out. Or if I’d had a long conversation with the patient, I’d note to her at the end of it, “Be sure and write down whatever.” So that wasn’t a bad experience for the patient either, in that they knew, from what they were saying, what I felt the kernel was.

Then toward the end, we would get to the assessment and plan, and I would tell the scribe the assessment. I would sometimes have to correct their spelling thereof, and I’d definitely give them the plan. And then we’d send the patient out to checkout. So what they needed to get out the door was there. As for the rest of it, if there was something that was going to be a pertinent note to be added to the chart, that would get added. With all the other stuff, the scribe would ask me, “Here is a question about something else that needed to be addressed,” but they wouldn’t do it during the clinic visit.

This enabled me to see more patients a day without going crazy. And I say going crazy because this was the flu season, three years ago, four years ago. Every January was crazy, and Saturdays in the clinic were crazy, and this enabled me to get through the flu season. Then I wanted to keep the scribe for the rest of the year, but they, at first I paid the scribe, because it was such a pleasure to have that extra pair of hands.

Sometimes you could ask that extra pair of hands to walk the patient to checkout to make sure they got there safely. You could ask the extra pair of hands to make sure the nurse knew to go ahead and set up a referral. So you could ask her for some extra tasks that weren’t always, something that you might have had to do, but you could ask her to do it: Walk the patient to the X-ray room and walk them back. I mean, there were things that were available, because the situation in that urgent treatment center was that you had a medical assistant who would get the patient in the room and triage them but wasn’t necessarily available thereafter, because they were busy rooming the next patient.

So this was a pleasure for me, because I felt I had a little more mental space, and if I needed to see 30 patients a day, I could do it without going crazy. I would still have to spend some time finessing the chart at the end of the day, but it helped with my mental health, because I wasn’t feeling burdened.

Kevin Pho: So in terms of downsides, one of the things that you mentioned in your article was cost. So tell me how the cost impacted the doctoring experience with the scribe.

Janet Tamaren: OK. Well, when this first started, I was just paying for the scribe out of pocket. I was feeling, “I’m making enough money per hour, and I don’t want to spend extra time inputting this. I can afford to divert some of that money to just pay for a scribe,” which the clinic let me do. I mean, that was OK with them to start with. At some point, they decided that maybe that wasn’t a good idea, and they wanted to take over, which seemed nice enough.

But as could be predicted, because it’s the cash flow thing, and I ran a clinic, so I know about cash flow, they decided at some point they couldn’t afford her, so they let her go. It was already kind of past the flu season, so I was kind of, well, I wasn’t happy about that, but I could deal with it. I knew it was going to be a cash flow thing, because I could see the billing questions coming in, and the money coming in, and the money going out, so I knew how they were approaching that. And I knew that this wasn’t part of their normal business plan, so I wasn’t going to be able to convince them otherwise.

Kevin Pho: We’re talking to Janet Tamaren. She’s a family physician. Her latest KevinMD article we’re talking about today is “To scribe or not to scribe? That is the question.” So, Janet, from a primary care perspective, like the one that you provide, or an urgent care perspective, for that matter, to scribe or not to scribe? What are your recommendations going forward?

Janet Tamaren: Oh, I wholeheartedly think anyone who’s entering the field right now, who is going to be in a busy clinic, and they’re going to be asked to work at the maximum, which might be appealing when you’re 30 and newly graduated from your residency (“Gosh, I can work, it just makes me feel important”), but maybe even at age 30, when you’re signing up for your first job, tell them you want a scribe. Say, “This is my condition. I need more help. If you want the EMR to be done and to put out all that data, which helps the billing company and helps the insurance company justify what they’re willing or not willing to pay, I want a scribe.” And it might be only at that point that you’ve got the power to insist on that. Or maybe it becomes a movement.

Kevin Pho: And my final question, Janet: What are some of your take-home messages that you want to leave with the KevinMD audience?

Janet Tamaren: Oh, OK. Well, after writing that, I started expanding it and thinking, what are the other ways that would make doctoring easier? Some other things that I think maybe new doctors, or maybe doctors who are getting tired, and I see that in the feed, and what with COVID and everything, you have to protect yourself. I mean, doctoring is hard. I don’t know if they said that to us while we were training. I don’t know if they gave us the ins and outs of how it’s hard, hard in various ways depending on what specialty you’re in. But in family medicine, you’re going to be hearing stories which are going to be hard to listen to, so be prepared for that. It’s going to take a toll on your heart.

There are a lot of ways you have to protect yourself. You have to protect yourself against these stories. They’re going to break your heart if you’re not careful. You have to protect yourself against people who are going to be bouncing things off of you, and they’re always complaining. People are always complaining. They don’t come in because they feel good. It’s shocking how many people come in complaining of pain, just shocking. They don’t come in just to chat.

So you have to be prepared for that, that your mental and your emotional reserves are going to be somewhat depleted. And to make up for that, you have to maintain your physical health. You have to seek refuge in something like exercise, where you leave the mental space where you’ve spent your entire day, go to a physical space, and do a workout of some kind. And there are just a couple of tricks for protecting your mental health. Those who make it through doctoring and don’t give up early and plan on retiring when you’re 40, I think they’ve all come up with these little tricks.

I have to spend time with my family. It helps. It’s therapeutic to ask a small child how their day went, because they don’t care. They don’t care how your day went at work. They don’t care if you had a hard day, if someone died, if you’re split down the middle by something terrible that happened. They don’t care. They just want to talk about fairies or something, and that’s good. That’s a very good way to replete your supply of good things.

I think it also helps to write, it turns out, because when I left the clinic, I started writing, writing down the stories that patients had told me, which is another way to put everything, to make sense of things, and to give acknowledgment to the patients who have taught you things, whether they wanted to teach you things or not, what you’ve learned from your patients. So it gives you the flip side of what it is your patients have given you. That’s a long view, though. That’s not something you acquire on a daily basis. It’s the long view about the patients who you can’t forget about, no matter how you try.

Kevin Pho: Janet, thanks again for joining me today and sharing your story, time, and insight.

Janet Tamaren: OK, OK. Thank you for having me.

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