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