I’m Equal Parts Doctor, Scribe, and Mouse Jockey

I’m Equal Parts Doctor, Scribe, and Mouse Jockey.

And I don’t love it.

When I gained acceptance into medical school, I thought I would one day have one amazing job, or at least one job title where I might get to wear several meaningful hats.

I wasn’t entirely wrong. I do have one job title. I’m a physician. Some days I’m referred to as a provider, but I’ve learned to ignore that term. To be more specific, I’m an anesthesiologist.

Some days, I’m referred to as an MDA, a term that, to the best of my knowledge, stands for the Muscular Dystrophy Association or any of seven different “M” states’ Dental Associations. I don’t like to respond to that term, either.

 

I am a Medical Doctor

 

I’m a physician. It’s my duty to play a role in improving the health and the lives of my patients. I studied and trained for many years to have the privilege of understanding the inner workings of the human body, the many ways it can be assaulted by disease, trauma, and time, and ways to combat those ailments to the best of my ability.

As an anesthesiologist, I have many tools at my disposal, and I help orchestrate the patient’s perioperative experience. I use medications, video laryngoscopes, long, sharp needles, ultrasound, and other innovative products and technologies to render a patient’s mind, or parts of his and her anatomy, insensate to pain during surgery. I ensure that the body’s systems survive with as little insult as possible.

When surgery is complete, I help alleviate the patient’s pain. That process actually started in the pre-operative holding area when I prescribed a few pills to take as part of a multi-modal approach to pain management, or when I performed the peripheral nerve block or placed a thoracic epidural catheter.

There’s a more personal side to my job, as well. I’m the calm voice discussing a patient’s health history and how it relates to our anesthetic plan. I instill confidence in the mothers, father, siblings, sons and daughters who are anxious for their loved one and what they’re about to endure. I can’t do it all alone. I work with a team that is focused on the same goals: patient safety and patient comfort.

I’m honored to have this job, and other than the occasional stressful moments, what’s not to love?

Well… I’ve only described about one third of my job. I spend just as much time sitting at a computer typing and clicking away, or at a desk or counter, filling page after page with bad handwriting until the day is done.

 

Writer’s Cramp Awaits

 

I work in two different facilities. In one, our documentation occurs almost exclusively on paper. At the other, nearly all the “paperwork” is recorded on a computer. Which do I prefer? Neither.

I’ll start with the paper program. On a busy day, I’ll arrive an hour before the first patient arrives in the parking lot. If I’ve got 30 patients, I’ve got 30 anesthesia pre-evaluations to fill out. That’s 30 lists of medications to transcribe. 30 past medical histories to read, process, and jot down in acronym form. 30 allergy lists to review and determine which drugs the patient could potentially be exposed to, and which among those might be true allergies. Epinephrine gives you the jitters? Good to know.

Some of this is done on the fly throughout the day, but a head start on the charts gives me a fighting chance to meet the day’s many other expectations without major delays.

If I’m going to be working at the same facility in the next couple days, I might spend a good 5 minutes each with another 20 or 30 charts before heading out for the day (or evening). I call it good when I’ve gotten through all the charts, or when writer’s cramp is threatens a permanent claw hand, whichever comes first.

 

anesthesia paperwork

 

The Computer Saves The Day?

 

At the 21st century computerized facility, we tend to have fewer patients. A shorter roster is a good thing, because it takes much longer to process each of them via computer, despite all that was promised when the electronic health record was mandated.

A wonderful feature of the computer is the automated compilation that occurs. In the old days, pertinent medical history was collected from the patient and written down, typed or transcribed. Now, all the diagnoses are compiled automatically from a variety of sources. Actinic keratosis. Seborrheic dermatitis. Compensated heart failure. Decompensated heart failure. Status post menopause. Peyronie’s disease.

Somewhere in that forest is a tree. All I have to do is tease out which trees are still standing, and which among those have any bearing on the patient’s health as it pertains to their upcoming surgery.

 

 

There’s also this super neat list called pertinent negatives. Sandwiched on the screen between the Problem List and Medical History, two lists which are similar but contain only partial overlap, exists a list of bad things the patient doesn’t have. Using the same font and appearing among all the diagnoses that the patient does have (or has had) are these things that the computer wants me to know the patient does not have.

Have I inadvertently mistaken something on this list for a pertinent positive? Yes, I have. Have I received cross looks from a patient and her husband when I said something about a cervical cancer that appeared in that list? Oh, yes I have.

At least when I sign the standard order sheet on paper, another sheet of paper doesn’t appear on top of the paper I’m trying to sign, alerting me to the same eleven irrelevant warnings that I see every time I try to sign the paper.

Thankfully, on paper, I don’t have to roll that extra-tall paper into a scroll and push a button to make it go away. The paper version doesn’t pause for five seconds, then ask me if the preoperative and postoperative orders should be associated with the operation the patient is having that day, and when I agree, make me wait another five seconds to let me sign them.

Can Scribes Ease the Burden of Medical Documentation?

 

The burdens of documentation have become quite onerous. I do understand the importance of documenting precisely what was done, but when a two-minute nerve block takes twelve minutes to “properly” document, the balance has shifted to burden.

I don’t have the solution, but in recent years, some specialties have found a way to shift some of that burden to hired teammates, the so-called scribes that serve as the doctor’s shadow in the clinic and his fingers on the keyboard.

In one study in a cardiology clinic, scribes increased productivity by 10%, resulting in addition revenue to the clinic of $1,372,694 at a cost of $98,588. That’s a nearly $1.2 Million net gain.

Is it time to consider scribes for anesthesiology and other specialties where they might ease the burdensome demands of documentation?

 

[PoF: I wrote this some time ago and have been hesitant to publish it. I tend to be a reasonably positive person, and let’s face it — this is a whiny post.

I decided it was time to release it when last week, changes were made to our order sets that unchecked some of our defaults. Nothing can be done about it, but I was assured our department’s order sets were on the schedule to be revamped so that we wouldn’t have to click an extra 6 to 8 checkboxes (with a few hundred millisecond delay for the check to populate the box) for each patient. When? In two years.

Unbelievable.]

 


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29 comments

  • Hatton1

    This a great post and goes a long way to explain why physicians burnout. My hospital changed the renewal of privleges application from paper to an online program. I have always given this to my office manager to fill out and just signed it. She could not figure out the program and neither could I. I ended up going to the medical staff office and filling it out with the credentialing officer. Total waste of my time.

    • I just love it when the “upgrade” to the system is a downgrade to our ability to work efficiently. Happens far too often.

      Best,
      -PoF

      • JustADoc

        Everytime my office EMR ‘upgrades’ it loses all my personalized settings so I cannot find anything. Takes 2-3 weeks to run across all the changes and either learn how to use them the new way or re-set my macros/etc.
        Then a month later there’s another upgrade.
        And people wonder why I am quitting?!?

        • Thanks for the comment, JustADoc, and I’m sorry for your troubles — not that I have anything to do with them, but I can empathize.

          You’ve highlighted an impactful result of all this nonsense — the EHR and MOC are probably the biggest offenders, but physicians are choosing to call it quits rather than swim upstream against the computerized record or endure another round of Maintenance of Certification.

          Enjoy your freedom!
          -POF

  • HospitalDoc

    It looks like you are using Epic platform. You can set your default with the Epic Order set user version. Don’t have to wait for two years 🙂

    • I wish it were that easy. You would have no way of knowing this, but you’re dealing with a bona fide Epic SuperUser.

      The first thing I did was go back to edit user order sets where all the nursing and lab orders were already pre-checked.

      After a number of e-mails were exchanged, I found out now that “we” have chosen to turn on “merging of Order Sets”, User versions of those order sets may not be ordered more than one at a time if the user wishes to have their customizations of the orders retained.

      So I can order one set at a time instead of the 2 or 3 I was previously able to order, but that takes longer than clicking all the extra boxes.

      Best,
      -PoF

      • Eric

        Painful. Possible labor intense but viable option is combine those order sets into one longer version. That gets you back to the pre-checkboxed setup. Works for ENT, not sure if it will work for you! Love the fact that your system made those changes without consultation then gave you a ridiculous time frame for customization. Good luck!

        • That was floated as a possible solution, but not every patient that needs PACU orders needs preop orders. When they are inpatients, they’ve already had an IV started, glucose checked, etc… but I’d rather place duplicate orders than do what we’re doing now. It’s more of a nuisance than a total hindrance, but it’s an unnecessary and new.

          Thanks for understanding, and may all tonsillar beds stay dry and intact.
          -PoF

  • Since I started practice 9 years ago we have added an additional 5 sheets of paper that must be filled out with every patient anesthesia record. We also have computerized order sets that must be initiated before the nurses can give any medications or even start an IV. If you forget an order, log back in to submit it, or risk suspension if you don’t sign a verbal order fast enough.
    The surgeons have it even worse with the computerized history and physical system. I actually sat there and had a hospital admin tell the surgeons it will only add 4 minutes per patient. Rounding on 20 patients, that is an extra 80 minutes they are staying at the hospital.
    I wish the people that implement these “improvements” had to practice evidence based form creation and conduct a double blind randomized control trial before submitting another form to show improved patient care.

    • The bloat from all this added nonsense is bigger than just the time those of us on the front-line put in. There’s also rapid growth in IT departments, experts to train and troubleshoot, people who track and report all sorts of metrics.

      The administrative bloat is getting out of hand, as well, and it all adds to the cost of delivering healthcare. The burden of proof, as you say, is not the same when it comes to documentation and changes to our workflow.

      Best,
      -PoF

  • You are missing another unexpected outcome of electronic records- message baskets. As an anesthesiologist I figure you do not have too many messages, but as a specialist I come into 20-40 patient messages a day and I know our PCP’s have close to a 100. These take time and mental energy. When I went into medical school in 2001 patient messages via email did not exist!

    Most would agree that while EMR’s have improved some aspects of record keeping, they have contributed to note and record bloat. I don’t trust the med list until I have reviewed it myself. This is like the old system and thus EMRs did not improve that aspect of my job.

    Nice post. Hang in there. A few more years and you ware done.

  • I wonder what makes your software so goddamn slow. Is the hardware old, or not spec’ed out properly? Is the code crappy and not performance tested? Is it syncing the cloud across a crap network connection?

    I work with software all day and if I had to factor in “oh wait. I’m thinking about that for a minute” every time I typed something, well, in the words of Russel Peters – somebody is going to get a hurt real bad.

    • I couldn’t tell you, but some of the hardware is looking pretty dated. The longest lag is probably about three seconds waiting for the procedure to pop up so I can associate the orders with today’s procedure. It doesn’t sound like much, but the eyes and mind wander with those lags, and it’s easy to lose focus.

      Keep up the good work and keep that software humming!
      -PoF

  • The hospital I’m at now uses Meditech and its frustrating how much time goes into charting. I would guess that I easily spend as much time with charts as I do with patients every day.

    I’ve used Epic in the past and it was a love hate relationship. I loved some of the new functions (search was pretty cool), but I hated the downtime and how Epic can vary in builds from hospital to hospital. When I would moonlight at various hospitals, even though I was using Epic at each place, it looked very different and lead to another learning curve.

    One of my friends has a job where they use Scribes and he tells me it has increased his productivity by at least 10-15%. Sounds tempting to propose to my hospital committee.

    I feel your pain though with EMR. At the end of my day I will easily spent 1-2 hours charting which is not fun and very frustrating.

  • As a patient it is frustrating, too. The Dr spends so much time dealing with the electronic side that they aren’t spending as much time with the patient.

    When our Dr’s office first switched over, the Dr, hated the software/hardware. She offered to let our son pee on the PC and short it out. Of course, that would have only caused minimal damage, the unit would just be replaced.

    The bloat goes far beyond Dr’s, too. The car we recently bought had about 15 pages more to process than the one we bought about 5-years ago.

    The documentation I need for my clients is about 3x as much as it was a couple of years ago and that was about 3x as much a few years prior to that.

  • I spend a LOT of my time either in jail or the ER (sounds bad to say it that way…whatever), so this goes a long way to explaining why the doctors in green scrubs are being chased around by teenagers in blue scrubs rolling a computer terminal with wheels.

    The doctors all look content and the scribes overwhelmed, but talk about an amazing work experience for them and better utilization of the doctor’s time!

    Cops aren’t worth a full time scribe. We are scribes…with guns. Still, many departments have noticed increased productivity through hiring a dictation service. I’ve heard great reviews, but Siri is my scribe when I’m too tired to type.

    Thanks for the insight!

  • Ac

    I LOVE having a scribe. My hospital wouldn’t provide one but was open to me paying, so I do and it has been worth every penny. I love my job, but saw some signs of burnout. The scribe has been so good for me and my family and my patients.

    • There is truth in what Ac is saying here.
      Do the calculation – how much does a scribe cost per day? How much extra work do you need to do to pay the scribe? How much time does that save? What other benefits are there e.g. not having cramps, frustration etc?
      PoF, is there a spreadsheet that can do this question justice? A scribe would cost around 200-300 per day, and for a Physician with RVU model, how much more will they have to work to afford that? Can this be covered just in the time they will save by not typing & mouse jockeying? Or potentially even increase productivity?
      For an outpatient Primary care Physician, it means two extra patients a day but saving 2-3 hours of EMR work. My source is a Physician leader, CMO of FQHC, who implemented scribes across their system because they were going to help reduce work load and increase productivity.

    • Beverly wife of pediatrician

      Any ideas on how it would work to have one physician in a partnership hire a scribe but other physicians have a choice to personally hire a scribe or go it alone? Would the scribe be considered an independent contractor providing services for the doc? How is the practice protected from liability from scribe errors if the scribe is not an employee of the practice? We are considering having the pediatrician’s daughter (nursing student and CNA) work as his scribe. Charting for 25 or so patients per day is usually finished by 10 pm or 11 pm. The day starts at 8 am or 9 am.

  • I agree that documentation requirements are one of the most burdensome aspects of medical practice. This might not work in anesthesiology, but for primary care and other office-based specialties, I think a cash-based practice is the best solution to eliminate oppressive billing and charting tasks.

  • PMAMD

    We have started using Scribes in our Internal medicine Primary care practice…They are MAs who do the whole visit with me, and increased our productivity by 40%. So you are Correct, with a right training, they are well worth the money

  • I love to rant. Unfortunately that is where medicine is heading–less patient contact and more documentation. I’ve seen some practices implement Google Glass as a scribing service. Not sure if it’s worthwhile, but if you are willing to spring for the cost, I guess it could make your life easier.

  • billy

    Even worse when you finally convince a patient that experiencing an episode of tachycardia is not an allergy to epinephrine, you cant erase/delete the epinephrine allergy from the pt’s medical record bc someone else entered it earlier (citrix/cerner- horrible program).

    • Ughhh… for years I was labeled with a succinylcholine allergy because I had sore muscles after getting it when I was 8 or 9.

      It wasn’t until I was in medical school that I learned it’s a normal side effect and not until residency that I learned a boy of that age should not receive succ for a routine case due to risk of death from hyperkalemia in undiagnosed Duchenne muscular dystrophy.

      Fortunately, I survived, sore legs and all.

      Best,
      -PoF

  • Chris

    I like how every other documentation heavy department is realizing the inefficiency of DIY dictations/notes except for Radiology. Every Radiology department uses the impossibly frustrating Powerscribe program, and it limits productivity significantly. “No evidence of,” often becomes “Evidence of…” and additional, less clinically significant (and more often missed) dictation errors are commonplace.

  • PA Educator

    As someone who sets up rotations for PA students, I have a few practices who find my students essential in their workflow for documentation (both EMR and paper). While my students are not officially scribes, they are happy to help. As long as my students have the opportunity to develop their diagnosis, assessment, and care management skills, the arrangement is fine with me. Our rotations are 5 weeks long. My students are very helpful in weeks 2-5.

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