Saturday, November 11, 2017

Privacy Violations: A patient's experience

Privacy Violations and how I dealt with them
by 'Still Standing'

(Moderators' note: This poster did not want to be personally identified to protect all concerned.  Although we do not favor this policy, his real identity is known to us, and we have permitted it as we have done on rare occasions before.)

I had a bad Patient Privacy experience at a VA Clinic and filed the complaint copied below. I prefer not to list the City or individual names, mostly out of respect because they have responded favorably to my complaint. The word Facility is the name of the VA Clinic, and the other Italicized words are similar substitutions. The medical procedure was in late August 2017.
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VA Facility Outpatient Clinic August, 2017
Dear Ms. Patient Experience Chief:
I am registering a complaint of people in my procedure room who had nothing to do with my procedure. Four times during my procedure the door was opened and people not part of my procedure were allowed to enter. This involved seven or more people. My privacy was invaded and my sense of modesty disregarded.
On The Day, a little before 8 AM I checked into Clinic C at the Facility VA for a scheduled colonoscopy at 9. My name was soon called and a woman introduced herself as Nurse. She said she would be monitoring my status during my procedure.
Nurse led me to the procedure room and closed the door. There was a bathroom off of the procedure room where Nurse gave me the necessary directions: Take off all your clothes and put them in this white bag. Put on this gown, it opens in the back. And put on these booties, you can wear your socks under the booties if you want. Nurse then left and closed the bathroom door.
When I came out of the bathroom the procedure room door was open and four or more people were standing in the procedure room, near the door, talking to each other and also talking to Nurse. There was also one or two people in the hallway who seemed to be involved with the people in the room and not walking by. The people in the room were dressed in green scrubs and scrub caps. One of the women in the scrubs made eye contact with me. Those people seemed to hurry wrapping up their conversations and left in a minute or two. The door was closed.
Nurse helped position me on the gurney and asked me if I wanted a blanket. I said I did and she left to get one. A man came in dressed in green scrubs and a hair net. He introduced himself as MedTech and said he would be assisting the Doctor during my colonoscopy. Nurse returned with the blanket. Doctor Last Name came in and introduced himself and said he would be conducting my colonoscopy. Soon the Doctor and MedTech were involved with their preparations in front of an instrument table.
A man came in dressed in civilian clothes, he walked up to MedTech and the Doctor and said “I had a great weekend, and yes, I can afford to retire in Reno.” He went on to tell them how he and his wife investigated real estate options in Reno. Evidently being in a good school district will raise the cost of buying a home, and that might not be a good value if you don’t have school age children. He also talked a bit about social and entertainment options that were readily found. Surely there must be even more to do if we just had time to look around.
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This man was quite happy and excited. He walked around the foot of my gurney and around the left side to a stool beside my head. While walking he looked into my gurney and strongly avoided making eye contact. He sat on the stool and told his friends that he and his wife also went to a city just outside of Sparks to look at a retirement community and at the general real estate market there. Evidently the retirement facility was nice but they didn’t imagine themselves involved with the social activities there. He said that 20% of the residents do not participate in those activities and so that community might work out for them after all. I could tilt my head up and left and look at him while he was talking. He avoided eye contact. When I looked toward Nurse she had turned her back. MedTech and the Doctor were facing this man and talking with him and they did not look at me. This man and his wife thought this little town outside of Sparks had a lot of potential and they looked forward to finding out more about it.
After ten minutes or so, I wasn’t wearing a watch, this man left. His exit path followed ninety percent of the perimeter of my gurney, during which time he did not make eye contact. I believe he is a staff member of VA Facility but I don’t think he is a member of the medical staff. He may not work in that building. If my procedure had required me to be exposed during his visit, then he would have had full view of my nudeness while he was visiting with his friends.
This man probably entered the room without knowledge of the exact procedure being performed, because he went there to visit his friends where they work: he wasn’t there to watch a colonoscopy per se. If I was there for a different procedure which required me to be fully exposed, this man would have been permitted to stay in the procedure room and have a full view of me. I do not know if he would enjoy having a full view of me, and I do not think that whether he would enjoy it or not is relevant. What is relevant is my sense of privacy. I do surrender my privacy for a medical procedure, but only to a medical staff involved with my immediate medical issue.
If an opposite gender patient had been in that room, and was exposed during her procedure, then that man would have a full view of her as long as he chose to stay and visit his friends. And I am not concerned that myself or other patients “have something” that this man or other VA staff “have not seen.” I realize that nude men and women have been seen before. I am concerned that I am required to be nude in front of people for no medical reason.
If that opposite gender patient had been sedated, or if I had been sedated, then “What the patient doesn’t know won’t hurt them.” Well, I disagree. Patients are affected by how the staff views them. When the staff views the patient as someone whose rights can be easily taken away from them, then the patient loses some humanity in the eyes of the staff.
Current VA Facility PRACTICE (not written policy, but practice) is disregard of patient privacy and modesty. Look at my experience, this cannot be a one-time oddity. This must be an environment. For various employees at the VA to have access to disrobed patients, without a medical reason, is disgusting. And when the patient is sedated it becomes creepy.
Returning to my procedure, there were two additional times when someone entered the procedure room. I believe it was the same man both times. He was dressed in scrubs and wore a scrub hat. He went to cabinets to put things in the cabinet and take things out of the cabinet. He made eye contact and offered a smile. I appreciated that.
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My procedure was completed soon after 9. I asked Nurse and MedTech about the man who talked so much and was not a part of the procedure. They looked at me with dull faces and said nothing. Is patient privacy a taboo subject?
As a patient, I surrender all Authority over my privacy of self and over my genital modesty when I enter a medical situation that requires it. When I surrender this Authority the medical staff cannot only take over this authority, they must also take the Responsibility that goes with it. The medical staff taking this authority from me is responsible to be a good steward of my privacy and modesty. The VA Facility medical staff holds my privacy and modesty in utter contempt.
This has got to change.
First, patient privacy cannot be a taboo subject. Patient inquiries cannot be stonewalled.
I received a procedure follow up phone call from TelephonePerson. She said she was sorry that people were allowed into my room who were not involved with my care. She told me there is an existing policy that only attending nurses and doctors are allowed in patient areas. I am sure she is right. I want to see copies of these existing policies. Perhaps these policies can be added to the Patient Bill of Rights. If VA Facility takes my complaint seriously, then I need to be copied on emails and reports about my complaint. There has to be an educational process to change this environment. I need to be informed about that educational process. This has to change.
Sincerely,
Patient name and contact info.
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I filed my complaint two days after the event. I looked up the Patient Advocate office at the Facility but the phone numbers listed were out of order, due to office renovations. I ended up calling the head of the department, Ms. Patient Experience Chief, whose office is at Headquarters in a Distant City, but I think I would have gotten the same response and results if I had started with the local Patient Advocate. I did enjoy talking the with the Department Head and at the time believed my case would be better handled by starting with her.
After ten days I got a letter from the Lab that the polyps discovered during the procedure were not cancerous. From that letter I also got the names and titles of Nurse and MedTech. I looked them up in the medical staff directory. A few weeks later I returned to the directory and their names were gone.
Two weeks after my letter I got a phone call from the Case Manager for GI Services, whom I will refer to as CaseManager. Mr. CaseManager was very encouraging and said there was an evidence of an
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environment problem with patient privacy before my complaint. He asked if he could send my complaint to interested parties, with my name and contact information. I consented.
That same day I got a phone call from Doctor LastName who thanked me for my feedback. He identified two problems: first that the patient was not sedated and second that the conversation was better suited for the break room. He assured me the man in street clothes (I said civilian clothes in my original letter) was the highest skilled nurse in the GI Department. He stated further that no one outside the GI Department is allowed in that area. He said that in every hospital and clinic there are people going in and out of procedure rooms that are not involved in the procedure in that room but they are medical personnel pursuing medical work in other rooms close by.
Remembering lessons I learned reading this blog and its’ articles, I addressed him by his title and last name and was relaxed when I spoke respectfully to him. I complained that the nurse had turned her back on me and that she and the technician had stonewalled me and that I had been generally treated with contempt. The Doctor responded that he takes care of the procedure and the support staff takes care of the patient. He would not directly address my question of whether friends would often drop in during times when the patient was sedated; in fact, everyone I talked to denied any knowledge of that one way or the other.
Three weeks after my complaint the CaseManager said the GI Department Chief had come from Headquarters, for the department monthly meeting, and had someone read my entire complaint to the whole department. They said that procedures had not been followed and the larger issue was that the patient should always come first. They had discussed incorporating my issues into on-going training.
I eventually talked to the Nurse Manager of the GI Department. She said they were installing signs outside each procedure room that would indicate when the room was in use, and also installing curtains in each room, three feet in from the door. If a staff person needs to get something out of the room, or to talk to another staff person in the room, then they will make that request and so forth, from behind the curtain.
In talking further with the NurseManager she confirmed that the invasion of privacy I experienced would never happen to a female veteran; because they have two important safeguards built into their system. One is the female veteran patient can request and receive a same gender health care team. Secondly, the female veteran is always accompanied by a medically credentialed, same gender attendant. NurseManager explained that the attendant would have stopped anyone who was not involved with the patient from entering the room. She was very proud of the service and respect they provide for the female veteran but acknowledged that it was not available for the male veteran due to personnel issues, all the men health care workers had been replaced with women; there were not enough men left to provide same gender care or accompaniment.
I left my conversation with NurseManager with a lot implied but unspoken. I was ready to take what victory I had and go. I also enjoyed talking with her in a respectful way and told her I considered the issue resolved, which she was glad to hear

Tuesday, March 28, 2017

Chaperone violation and resolution



AMBUSHED BY A “CHAPERONE"
How to resolve the issue 

by RG

Moderators note:  This post is anonymous at the request of the author.  However his actual identity is known to one of us. 
For more background on this topic refer to the article on chaperones and the article on privacy complaints.


                                                                                                                                               

I get my most of my health care from a large group practice in the town where I live; one of my two  primary care providers there was a female nurse-practitioner who I’d been seeing for 5-6 years and had a good professional relationship with. Last summer, I was taking a shower and noticed a large swelling on one of my testicles. Knowing this was not something I could put off, I immediately made an appointment with my NP, who fortunately was able to see me that same morning. I was a little self-conscious about being examined by her, but based on our prior history – and the fact that I’d had intimate exams from other female doctors over the years -- I figured I could get over myself.
Anyway, after talking with me briefly about the swelling I’d noticed, she got up and went to the sink to wash her hands. “When was the last time you had a testicular exam?” she asked. Not exactly an announcement of what she planned to do; on the other hand, I knew it was coming, so I wasn’t surprised. “This will be my first,” I said. She nodded, then instructed me to take my pants and underwear down to my ankles, lie down on the examining table, and cover myself with a large cloth. She left the room for a few minutes while I did so. But then, when she knocked and opened the door again, one of the intake nurses (also female) was right behind her. Without a word, they positioned themselves on either side of me, directly across from each other at my hips. Then the NP pulled the drape completely off me, exposing my genitals to both women. I was so shocked and embarrassed I literally couldn’t speak – the NP hadn’t said anything beforehand about bringing in a witness, and obviously hadn’t asked my permission for someone else to be in the room. Before this experience, I had never even heard of “chaperones,” and had never been undressed in a doctor’s office for anyone but that doctor. The other thing that bothered me was that the nurse literally did nothing the entire time but stand there staring at my exposed equipment. She did not say a word to me or make eye contact at any point, and wasn’t assisting the NP in any way. As soon as the exam was finished, she turned and left the room.
The swelling turned out to be a cyst, and I was referred to a (male) urologist who recommended surgery to remove it. That took up most of my attention for the next several weeks, during which time I noticed some glaring differences from my initial exam in terms of modesty acknowledgement. I’ll just give you two examples. First, a female ultrasound technician who not only didn’t demand a witness, but made sure to drape me in such a way that only my testicles were exposed and nothing else (not even my bare thighs), and only while she was actually examining me. When she had to stop for a few minutes to check her records, she readjusted the drape so that I was completely covered until she returned to resume the ultrasound.  Secondly, in the recovery room after my surgery, the nurse attending me asked if I would like her to change places with my wife when getting dressed to leave – an offer I gratefully accepted.  Gradually, as I pieced together my memories of the initial exam, I began to realize how seriously and unnecessarily my privacy had been violated. At that point, I sent a letter to the NP, asking why the nurse had been present and why I hadn’t been consulted about it. She replied in a 4-line email stating that it was her “policy” to have a witness present whenever patients were undressed, that it was “for your protection as well as mine,” and recommending that I see a different provider in future for intimate exams. I took her advice a bit further, and sent her another note terminating our relationship. I obtained a copy of her clinical note for the exam, which to my surprise did not list the name or credentials of the witness, just the phrase “Chaperone during exam: female present.”  I went back to the facility in person to get that information; the clerk I spoke with seemed surprised that I was asking, but obliged me.
Since the NP’s response was so unsatisfactory, I decided to follow Dr. Joel Sherman’s recommendations (see http://patientprivacyreview.blogspot.com/2010/10/privacy-complaints-what-to-do-about.html), and gradually worked my way up through their chain of command (threatening to file a complaint with the state medical board probably helped). Ultimately, I was invited to meet with their two top directors. I told them I preferred not to seek disciplinary action, but did require an acknowledgement that both their NP and their nurse had acted improperly, along with some meaningful protections that would keep me from being placed in that situation again. I pointed out the implicit double standard in allowing two female staff members to attend an undressed male patient; they agreed that the reverse situation would never be allowed to happen at their facility, but said that the small number of male nurses on their staff made that double standard difficult to avoid. I offered to sign an a priori waiver of legal liability in exchange for a universal exemption from “chaperones” in their practice, but they did not agree to it. Their position was that individual providers had a right to third-party witnesses if they desired. Instead, they told me they would post a note in my electronic chart so that any provider in their practice would know my wishes in advance; they also agreed to attach a letter from my therapist, stating that the presence of such third-party observers was emotionally harmful for me. Their thinking was that any provider seeing that information would be likely to respect my preference and not be worried that I was just looking for a way to trap them into a lawsuit.
At my request, they also gave me some advice for negotiating with any new providers: if circumstances permitted, I should arrange for an “establish care visit” in which the provider and I addressed my refusal of witnesses and came to some agreement in advance about how to proceed. In the event of an urgent situation, such as I’d had with my cyst, and the new provider was not willing to work without a “chaperone,” I could ask that provider to switch places with a colleague who would honor my wishes, so that I wouldn’t have to delay treatment by rescheduling.
In our meeting, the directors also announced that they were planning to train their entire staff in proper chaperoning protocols – something they admitted they had not done previously. I asked for, and subsequently received, a copy of the informational materials they developed for this training. To their credit, every one of my complaints is being addressed: providers know they have to announce their intention to have an observer beforehand and specifically ask for consent; “chaperones” themselves are explicitly instructed to be attentive to patients’ signs of vulnerability and embarrassment, and to provide reassurance -- verbally and by maintaining eye contact. The training materials also clearly state that opposite-sex witnessesc are equally inappropriate for male and female patients, thus apparently ending that double-standard at their institution. I sent a written reply, thanking them and commending them specifically for their progressive stance on male modesty.
In closing, I’d like to offer my thanks to Mr. Capra for hosting this site, and to everyone else who has posted here. Your thoughts and shared wisdom helped me learn how to advocate for myself, and to believe that change is possible if one is willing to help make it possible.


Monday, November 24, 2014

Masculinity and Men's Health



EMBEDDED STEREOTYPES
Masculinity and Men’s Health Care
by
Doug Capra

            What does it mean to be a man? How do we define masculinity? What does a “manly” man look like, sound like? How does a real man behave?
            More importantly, who gets to decide the answers to these questions?
            The Movember Foundation is a respected global organization committed to changing the face of men’s health care.
How? By challenging men.  They challenge men to grow mustaches during November to raise funds and open up dialogue about prostate cancer, testicular cancer, and mental health issues. Since 2004, they have raised over $550 million and have funded over 800 programs in 21 countries. They are an honorable organization.
That’s why I was surprised recently to read a press release promoting this mustache-growing event that contained the following sentence:
“Most men aren’t proactive about their health because they’re ill-informed, lazy or scared. And that’s not manly.”
I’m not questioning the intent of the article. Getting more men to be more proactive about their health is an exemplary goal. But calling men lazy and unmanly?   And how dare a real man be scared. Real men aren’t supposed to be scared, are we? If we are, we’re certainly not supposed to verbalize it or show it in any way. On the other hand, realistically, who wouldn’t be afraid of the possibility of prostate or testicular cancer?
I couldn’t imagine this kind of language being used when the pink ribbons are distributed and women are urged to get checked for breast cancer? Why then do some believe it’s acceptable to use this language to convince men to get health care?
I immediately checked the Movember Foundation website  and read through it. I first went to their visions, values and results section under “about us.”  Everything I read showed tremendous respect for men, so I couldn’t imagine this language coming out of the Movember Foundation. So I sent an email to Movember inform them about this incident and asking if the press release came from them. I immediately got an email back from their representative, Abbie Rumery. She wrote:
“Thank you so much for reaching out. Was this a press release that was put out by a local community group, or was it in a news article that you read? That is not something we would ever say or promote on our website. Movember is all about getting guys to feel more comfortable talking about their health and breaking down stigmas and barriers related to their physical and mental well-being. If any organization is looking to promote their involvement in the Movember campaign, I would normally send them this digital press kit and the attached one pager and press release template. None of which say anything about men not being proactive about their health because they are lazy or scared and that it’s not manly.”
I hadn’t thought those words came from the Movember Foundation. That wasn’t their style. But then – where did that press release come from? I eventually found out, and I was further disappointed
I learned that what appears to be the original article is on a website belonging to the UMC Health System. They claim to be “the leader in comprehensive healthcare delivery in West Texas and Eastern New Mexico.” They say they reach “more than 300,000 patients a year,” patients that have “come to expect our dedication to service and the top-tier care we provide.” I’m not certain that this article originated there; it could have been reproduced from another source. But that’s not an excuse.
I sent an email addressed to four of UMC Health System’s top officials. I’ve not gotten an answer back from them and I note as I write this that the link that contains the sentence about men being lazy and unmanly is still up. You can find it here.   The fact that they haven’t returned my email is also disturbing. By ignoring controversies you just raise more disturbing questions. Did they think my email was from a crank? Do they consider my complaint unjustified or irrelevant? Or do they really believe that many men don’t get health care because they’re lazy and unmanly? By not facing the issue, they leave these questions unanswered.
I’m one of the men who is proactive about his health, and although I’m not a health care professional, I’m actively involved with health care issues. I frequently urge men who aren’t as proactive as I am to get checkups. But let me suggest that there are better ways to persuade them than by calling them “lazy”-- and saying that being afraid – a reasonable response to serious disease – is “unmanly.” Yes, many men are uninformed about health care issues – but not more than the population in general.
The real question – that is rarely asked and rarely researched – is actually why these men (and some women) don’t seek healthcare. And let’s not leave out that high costs may be one reason. Even with insurance, some patients can’t afford the deductibles.
Catherine E. Dube, EdD, has been doing research into men’s health attitudes for years. She and her colleagues published “Talking with male patients about cancer screening” in the Dec. 17, 2004 issue of the Journal of the American Academy of Physician Assistants. They wrote:
“Clinicians may hold certain assumptions about male patients that are not well founded. Clinicians may believe, for example, that men are immodest and unlikely to feel embarrassment during genital exams, don’t care about their health, are emotionally insensitive, and will seek medical care only if pressed to do so by a woman in their life. In our focus group research, however, we discovered that men were surprisingly modest about physical exposure in clinical settings, concerned about embarrassing exams, and interested in their health. We also learned that they desired closer personal relationships with their health care providers.”
This can be a sensitive issue that is worthy of much more discussion than I have time or space to offer here. Dube and her colleagues also wrote:
            “Understanding male communication and behaviors has become even more important with women entering the health professions at ever increasing numbers. Stereotypes held by practicing clinicians and handed down to trainees need to be challenged and adjusted to provide more effective care to men. Since men are less likely to be connected with the health care system than women, special efforts should be made to encourage appropriate preventive care, including age-appropriate cancer screening and early detection strategies.”
This article was published ten years ago, and perhaps we have made some progress – but not nearly enough. Indeed, the health care system is under even more stress today than it was then. Rising costs place a tremendous stress on efficiency. Safety, quality, standardization and patient experience issues dominate many a discussion in medical boardrooms.
And patient experience is an especially hot topic today. Some experts in customer service will tell you that the medical community, generally speaking, is twenty-years behind the times. In the early 1990’s a team from the Harvard Business School, Pine and Gilmore, published a book called The Experience Economy. Consumers were not merely after food or coffee or beer, they contended. They wanted an experience. That’s what they would pay for. They pointed out how Starbucks turned a commodity into a successful experience. Disney may have started the movement, or at least perfected it – but other businesses followed.
The patient experience begins with the patient’s first encounter with the system.
At the end of their book, Pine and Gilmore said that the experience economy has already peaked and we’re moving into what they called the Transformation Economy. Consumers don’t just want experiences, they want peak experiences that will transform their lives. We see that today especially in the tourism industry.
As we’ve consistently pointed out on this website, medical modesty and privacy are extremely important values for some patients and very important for many others. We’re not claiming that most or all men who avoid health care do it for modesty reasons – but certainly some do – as do some women. One of the key elements of American capitalism is choice. Patients in general, both men and women, should be offered the caregiver gender they feel most comfortable with, especially for the most sensitive exams and procedures. This may be one reason why some men and women don’t seek the care they need.
Certainly, we can push people into all kinds of behaviors by using name-calling and guilt. But that’s not persuasion. At its best it’s intimidation. At it’s worst it’s bullying. Of course, if one believes that the end justifies the means, than I suppose anything goes.
But the idea is to create lasting change, a “transformation,” -- not just one visit to the clinic where the experience may or may not be positive. The idea is to get rid of sexist stereotypes in both language and practice and start dealing with reality. Most men at heart want to stay healthy, not just for themselves but for their families as well. They may be afraid, but that’s natural. They may be strongly influenced by masculine stereotypes themselves and feel they can’t be afraid or embarrassed, or express their true feelings to health care providers. Certainly, telling them that this fear makes them “unmanly” is counterproductive and plain wrong.
But we’re not only dealing with the stereotyped attitudes some men may have been raised with.  We’re also dealing with attitudes from the medical community as Catherine Dube points out in her research.
As the month of November ends, let’s not drop the issue of men’s health. Let’s keep it open. And let’s all of us start taking openly about the issues that prevent men and women from seeking the health care they need to better their lives and those they love.


Friday, April 11, 2014

Medical Scribes, an Evolving Threat to Patient Privacy

by Joel Sherman MD


Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance.  There is no accepted definition of what scribes do or what their background or training should be.  There is no mechanism for licensure of them in any state.  They are poorly defined medical assistants.  The field is in its infancy and its ultimate role in our healthcare system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry.  This may or may not involve being present for the history and physical exam.  Most commonly they are physically present in the room and witness the entire encounter.  The need they fill is a function of our ever increasing mandates for electronic medical records (EMR).   Before EMRs, the use of data processors in examining rooms was quite rare.  Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all.   Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized.  The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal.  Some advertisements require applicants to have a high school diploma or a year or two of college.  Many make no mention of education at all.  Some commercial sites train the scribe for a period varying from a few weeks to months.  At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student.  This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications.  The majority of practices will not have access to premed or med students.  The scribes are mostly young and it is likely that few will choose this as a permanent career.  Thus they constantly have to train new ones.  The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr.  The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry.   It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice.  Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with.  The dangers to patient privacy are clear but not often emphasized.  How much of a concern this is depends on the practice.  My ophthalmologist uses them without difficulty.  Few would object to an assistant hearing your ophthalmological history.  But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant.  A few have the assistant outside the room for this perhaps making the patient more comfortable.  The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable.  One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document[1].  This took place in an academic setting with medical students used as scribes.  The majority of the scribes were in fact men.  The one female urologist in the practice with a predominately female following refused to be part of the study.  I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background.   The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice.  The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy.  But in emergency settings patients are less likely to be concerned about their privacy.


The accuracy of scribes has not been studied to my knowledge.  The results would depend greatly on the background and training of the personnel.  But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.  The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use.  If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy.   I don’t see how scribes without a medical background could ever be competent to understand a general medical history.  It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes.  This would also permit a far greater feeling of patient privacy.   Patients have always understood that their medical records may be processed for administrative purposes.  The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient.  They should not be used as chaperones or multipurpose medical assistants without further special training.  In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves.  There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries.  This makes it increasingly impossible for solo physicians and small groups to stay in practice.




[1] Koshy S et al, J. Urol. Vol 184, 258-262, July 2010.

This article has been re-published on KevinMD.com.