Replacing transcriptionists with physicians is a fool’s bargain

My general internal medicine practice is equidistant from the three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.

The notes I receive back from one of these organizations are hands down the best of the four institutions. These notes are personal, concise, precise and clear. If the patient had a complicated outpatient work-up the communicating physician will send a problem-oriented summary of the patient’s symptoms, the work-up, the conclusion and the recommended next steps. There is a clinical narrative with clear communication of the patient’s unique story and the medical decision-making. Furthermore if the patient saw more than one physician, the note I receive integrates the impressions of all of the physicians.

For my patients hospitalized at this institution I especially value the discharge medication list, which is broken down into fields for continued medications, modified medications, new medications and discontinued medications. In most circumstances the patient has also received a copy of the inpatient and outpatient notes and the medication list.

From the other organizations the communication is rather more like a “ransom note,” a multi-font collection of structured text entries, pieced together with imported labs and x-ray results into a hard-to-read document, typically 6 pages of structured text, with an emphasis on billing justification and compliance language. Scanning through these lengthy documents for the “meat” of the note I struggle to find a coherent story (but I readily see what type of learner the patient is, and what part of the visit the attending was present for and other billing and compliance information.) Three different EHRs are represented. Here is a typical emergency room note:

“The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope”

Transcriptionists are being replaced by physicians for cost reduction, a calculus that doesn’t consider reductions in patient safety and quality, or lost physician productivity and well-being.

This “savings” in transcription costs also comes at a cost to the clinicians who subsequently read through multiple pages of low value text to find the kernel of useful information. And because the person documenting the care spent considerable time processing through the drop down boxes, less effort has been applied to the assessment and plan, often leaving the receiving physician in the dark when trying to pick up the thread of care.

I have always appreciated the care my patients receive at the first institution, not just for the care itself, but for the systematic, reliable communication I receive back about my patients. I recognize that having one physician summarize complicated care across many specialties, and having dictated notes is an expense, but it is an expense that makes a difference in the care of patients. Replacing transcriptionists with physicians is a fool’s bargain.

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations.

Here’s why you wait in the ER

All have to wait. As is normal with all the busy ER, the ambient sounds of machines, alarms ringing, debilitating moaning, and loudly drunken outbursts permeate the section. It is a controlled insanity.

But, a girl’s scream pierced my spirit. Her baby eight-month-old boy put back in her arms. He is already pale, lips his torso not climbing as it must with breathing — that he is not reacting at all. We wasted no more time. Nothing brings help quicker to a room than a dead kid. We rapidly put a breathing tube, then started pushing on his small chest with our hands to help keep his heart beating, then drilled an IV to his bones, and pushed into all the drugs we could. Ten minutes passed. Nothing. Twenty minutes passed. Still nothing. For every other patient, we might assess heart motion and if it’s not moving, pronounce the time of passing. Not for children. Never for Kids. We spent 45 minutes for this baby. Helpless, the time had finally arrived. We were in agreement. Time of departure: 0205.

The heartbreak isn’t over though. Next is the mother. What would you say? Not much. I could just sit and try to absorb her despair, her skepticism — her remorse.

What’s next? We move on. It’s a hectic night… the damage had ripped into me, but I had more hours to operate; patients are awaiting. The next patient was waiting for two hours. I took a pause, massaging sanitizer involving my cold hands a couple of seconds longer than normal to compose myself. What occurred following etched into my head as far as the tragedy that happened minutes ago.

The patient berated me. Yelled at me personally. “I’ve been waiting for hours to see the doctor! What type of place is that!? You are supposed to treat me, not leave me waiting! I knew I should I’ve gone someplace else!”

Never have I felt this way.

“I’m sorry for your wait. It’s been busy,” was all that I could muster.

Maybe, if this person knew what had happened, there could be some comprehension — when the doctor has not talked to you yet, there is somebody sicker needing attention.

But we can’t say . I can’t say a kid has just expired. I can’t tell you that a seven-year-old girl’s figure, was ripped by a stray bullet. I can not mention that we just consoled a weeping family. I can not.

Our fast-paced culture needs convenience — click on a button to arrange clothes, instantaneous posts on Twitter, receive a hamburger by means of a car window. That which we’ve lost, however, is a tiny comprehension of the human condition — compassion for others. Sometimes we are so excruciating, we can’t see past our own hospital gurney. Nowhere is that more evident than the ER.

Triage must occur. With limited, exhaustible resources we must do what emergency departments are made for: take care of the sickest first. There’s a saying in medicine:”Vitals signs are essential.” That is where we begin.

By way of example, two patients require evaluation.

One is really a 30-year-old man with stomach pain with normal vitals — waiting hours.

The next is a 60-year-old lady with chest pain, quick heartbeat, low blood pressure — waiting ten minutes.

Who’s first? The choice is obvious. Without emergent therapy, patient 2 will perish quickly. Patients #1 might need to wait longer, but patient #2 doesn’t have this luxury. ER physicians will make this choice every single time without hesitation.

We are responsible for the whole ER, its people, and its finite resources. It does not matter who you are, the ER is the excellent equalizer.

For all our patients, we recognize this is among the worst days of their life. We try to deal with it like that. Regrettably, at the ER, somebody else is constantly sicker than you personally.

Admittedly, there are more factors beyond doctor management. The flow of this ER is much like this a five-lane freeway. When everybody goes the exact same rate, traffic flows nicely. When rush hour hits, more automobiles merge in the on-ramps and visitors slows. The ER also slows only by sheer volume. In case a semi-truck crashes, automobiles come to a stop before that truck is cared for. Likewise, we must tend to that gunshot wound to the chest before focusing on the others. The truck must be cleared to permit others to pass. When the destination is outside of parking areas, individuals are left unattended around the freeway. After the hospital is complete, the ER becomes crowded. The patients which need to stay in the clinic? We keep them at the ER, there is nowhere else.

No one likes excuses. If it was possible, we’d evaluate everybody instantaneously. Waiting kills. We know this. That’s why we are constantly developing methods to improve wait times. We’ve placed doctors in the waiting room, acquired blood work and X-rays straight away, streamlined workflow with different specialties and generated different areas to view less critical complaints.

Yet, it is insufficient. Folks will wait. People have emergencies. Doctors fill up. It’s sometimes tough to wear a different patient’s gown and step into their slippers, particularly when we are hurting ourselves. But that is what makes us human — why we appreciate society. As soon as we view a fiery crash on the freeway we expect that nobody is hurt and there are survivors. We understand why we need to stop our automobiles. Our basic instinct would be to wish the best for people.

The ER is an overwhelming place — especially for patients. Several factors contribute to the wait time — many supporting the ER doors, beyond our control and beyond our patients’ sight. We might be in pain and we all might be in need, but our empathy for our humanity can make it more tolerable.