Thursday, January 28, 2016

Medical Scribes and the Patient-Doctor Relationship

I'd heard and read about the practice of bringing "scribes" into the exam room to allow the doctor to relate to the patient rather than to the keyboard. But I hadn't experienced the phenomenon until last week. 

Prior to my appointment I was told that the physician I was about to see (my primary care physician has been ill, and I was seeing a physician I'd never seen before) worked with a scribe. Would that be OK with me? It was. The medical issue involved my big toe and foot, and didn't feel enormously personal.

The photo (it isn't me) shows the scribe interacting with the laptop but clearly in the patient's line of vision. At my appointment, when I looked at the scribe he was looking at me - we made eye contact. He said nothing verbally or via facial expression, but was clearly a third person in the office. Since the focus of the examination was my foot - not a very personal exposure - and the questions weren't about intimate matters, I didn't mind having a non-clinical stranger in the room. But if either of those conditions were different, I would not have wanted the scribe to be present.

The impetus for using scribes is directly related to the electronic health record and the incentives from Medicare (and others) for using the EHR. If physicians are doing the entry, it's either during the appointment or after. Entering the notes during the appointment is more efficient, but leads to the common patient complaint that "the doctor is treating the computer instead of me." But entering the notes after the appointment requires additional time that is not reimbursed and makes the working day longer. 

During my years of psychiatric practice I regarded myself as a devoted clinician. I loved my patients. But from residency on I generally made my notes during the appointment. I found that if I waited until the end of the day I'd forgotten things, and after a busy day of appointments I felt burdened by the additional time requirement. I didn't resent staying later to see a patient with an urgent problem, but I did resent writing notes rather than heading home to be with my family.

I can't believe that voice recognition technology can't make it possible for doctors to dictate notes while seeing patients. It could be done in a way that helped the patient to understand our thinking. From residency on I always wrote my notes with the assumption that the patient would read them. The discipline this imposed was useful. As an example, it helped me in relating to people with paranoia. I didn't write "Mr. Jones is paranoid and delusional," but rather "Mr. Jones believes extra-terrestrials have implanted a chip in his brain. He understands that I do not share this view. We discussed why I believe taking anti-psychotic medication would help him in his life..." 

I found that people with paranoia appreciated that I recognized the possibility that (in this example) extra-terrestrials might be causing mischief, but that I found this extremely unlikely. We could frame using medication as a hypothesis - "whether or not there is a chip in your brain, I believe that you will sleep better and be less afraid after a few weeks..." rather than as the equivalent of "you're crazy and I'm sane so you should do what I say..."

Writing notes with the patient in the office allowed for discussion of what should be said. With someone I'll call Mr. Jones, it had taken quite a bit of time to elicit a clear picture of how much alcohol he used and how alcohol might be affecting his mood and his physical health. I explained why I thought it was important for his primary care physician to know about his alcohol use. We sat together in front of the terminal to compose my note. Mr. Jones baulked at the word "alcoholism," but accepted "alcohol problem." This wasn't just a piece of collaborative writing and editing - it was an integral part of the treatment process.

It seems to me that the burgeoning of medical scribes is a workaround pseudosolution for a broken health care system. Adding a third party to the appointment is better than burning out our physicians - an all-too-frequent occurrence. But the real fix would be a combination of more realistic expectations for documentation and improved electronic health record technology. 

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