Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

#1 - Let's Elevate the Role of Medical Scribes

12/22/2015 8:38:59 AM | 2 comments

In our most popular post of 2015, an emergency physician shares the many ways scribes help to improve his morale, efficiency and interactions with patients.

We all know that scribes can help to improve operational efficiency, quality metrics, patient satisfaction, documentation and more. But in this post, I'd like to talk about the more human side of that role.

A Unique Partnership

My first experience working with a scribe came when I joined CEP America. I was really excited about it. I'll admit my expectations weren't terribly realistic. Part of me expected a robotic data transcription machine that would magically understand my thought process, capture only the essential patient historical elements and ultimately transform my rambling into a coherent chart.
Of course, in the real world, it's a little more complicated. Scribing takes conscious effort from both parties. But as I gained more experience with scribes, I found that my documentation improved. I also became more efficient, which often translated into better patient care.
But something surprising also happened. I mysteriously began deriving more satisfaction and meaning from my work.

Unexpected Benefits

As an emergency physician, it's nice to get the big save. But it's also so rare, you can't rely on it to keep you motivated. On the other hand, working with a scribe provides many small victories — not to mention a buffer against some common occupational hazards. Things like:
Quality time with patients. On the days when I work with a scribe, there's a noticeable difference in the quality of my patient interactions. Instead of fighting with a laptop, I can focus more attention on the patient and family, which improves everyone's satisfaction.
Victory over EHR. When a scribe is "on," it's like we're waging EHR warfare together. It still amazes me to see them with multiple records open on two screens, capturing information that's being blasted at us as if from a fire hose. One second they're taking notes on a phone consult, the next they're entering EKG test results I read aloud. It's really kind of amazing to watch them in action. I know I couldn't do it nearly as well (and prove it to myself on those occasional shifts when I go scribe-less).
A second frontal lobe. A strong scribe provides information management far beyond the electronic realm. While I'm on a call with neurosurgery, the scribe fields patient information from the nurses — making notes, interrupting when something can't wait. And I shudder to think how many missed ancillaries and PQRS metrics I'd have foregone documenting without a scribe prompting me for a key piece of data.
Company. It probably sounds weird given the crowds and interactions involved, but working in the emergency department (ED) can get lonely sometimes. Providers, nurses and technicians are all working under time pressure, which means most of our interactions are pretty task-focused. The scribe, on the other hand, is with me every minute of my shift and knows what I'm going through. They empathize when I'm being pulled in eight different directions. They serve as my reality check that yes, we really are having a ridiculously busy night, and neither us of have eaten or used the restroom in a while. And they share all the funny, touching and ironic moments that just aren't as meaningful when you're alone.
Idealism. Most of our scribes are college students (or just out) who hope to use the experience as a stepping-stone to medical, nursing or physician assistant school. They're excited about what they do and what I do. When you're coping with the daily rigors of value-based purchasing and quality metrics, it's refreshing be around someone who truly believes that your job is the coolest job ever. They take me back to that time in my career when I was extremely optimistic and enthusiastic about medicine. It's a daily reminder of the fundamental reasons I went into it and what it represents.
Positive peer pressure. One busy night I was resuscitating a patient — literally in the middle of putting an endotracheal tube in his airway — when a nurse called through the door, "Hey, Bed 13 is feeling a little nauseous!" Well, you can imagine all the snarky, not-so-polite responses that went through my mind. But because the scribe, the future professional, was sitting a few feet away, I somehow held my annoyance in check.
Sharing the ups and downs. Not long ago, a man with advanced laryngeal cancer died of a tragic tracheal hemorrhage in our ED. My scribe on that shift seemed unusually shaken up. Later, she told me that her own father had died of cancer recently, and it struck a chord. While I've conditioned myself not to identify with patients' suffering, her experience really moved me. For a minute, she shook me out of my carefully compartmentalized mindset and reminded me what our work means to patients and families. It left me appreciating what's really important in medicine in a way I hadn't since my first clinical rotations. (And I hope I was able to be there for her, too.)

Elevating the Role

As you can see, I'm a huge proponent of the scribe role and what it can accomplish. So imagine my surprise when I learned (from the scribes themselves) that some health professions programs don't consider scribing as "clinical experience" during the admissions process.
Really, let's think about this. These scribes may not be drawing blood, running lab tests or delivering first aid, but they're getting an incredibly rich view of what clinical practice entails. That scribe is with me for hours at a time, hearing my thought process as I'm going through my medical decision-making. They watch me interact with nurses, do discharge planning with case managers, weigh admissions decisions and watch every procedure I do.
They also get a good feeling for what patients experience. They see the person who comes into the ED for a medication refill because they have a few days of blood pressure medication left and can't get a primary care appointment for 12 weeks.
And yet, to get credit for their clinical experience, scribes sometimes have to go through an appeals process and educate the admissions committee on what a scribe actually does. It’s madness, I tell you.
Of course, this may change as scribing becomes better known in the healthcare community. In the meantime, I see a real need to elevate the role.
For one, I don't think the title "scribe" really encompass all they do. "Scribe" calls up an image of someone in a room transcribing data, not someone who's a dynamic participant in the care process. That's why I'm on a mission to change the title from "scribe" to "clinical information manager."
In the meantime, when a scribe asks me for a reference letter, I usually go the extra mile to not only explain why they'll make an amazing healthcare professional but also to expound on the significance of their role.
Scribing is about so much more than the EHR. This person is living every decision and patient encounter with me, minute by minute for hours at a time. I can't think of any better preparation for a medical career. 

Jason Ruben, MD, Director of Scribe Services at CEP America
RLU, thank you for raising the issue of patient privacy, because it's important. If it helps, here are CEP America's expectations for our doctors regarding patient privacy:

* The patient decides who is in the exam room, period. Scribes, students, and residents may not be present without patient permission.
* Providers must introduce the scribe, explain the scribe's role, and ask if the patient is comfortable with that arrangement.
* Throughout the encounter, the provider should remain sensitive to potential privacy concerns and dismiss the scribe when these might reasonably arise.

While no set of guidelines will be 100 percent effective, we've found that this approach minimizes privacy issues while allowing  a more natural interaction between provider and patient. 

Lastly, there have been a few (non-published) studies and surveys that indicate patients overwhelmingly don’t mind when a scribe is present with  their physician. In fact, patients report that they like that the physician can now focus on them and not the computer.
4/18/2016 12:42:14 PM

I understand how scribes can be beneficial for the doctor and for the scribe but these discussions never seem to focus on patient privacy. Why should patients think it is OK to have intimate exams in front of college age scribes of the opposite gender? If my doctor doesn't respect my dignity enough to at least have a male scribe come into the room, either the female scribe leaves or I do.
4/11/2016 7:12:44 PM