Scribes: Helping Overworked Primary Care Physicians

Doctors and patients alike have experienced rising frustration as physicians using electronic health records bury their heads in computer screens, rarely making eye contact while listening to highly personal tales of sickness and woe.

But a Northern California community clinic has found a solution to this technological glitch that calms frustrated patients, frees overworked physicians, and improves the clinic’s bottom line.

Shasta Community Health Center (SCHC) in October completed a successful pilot program that paired “scribes” with physicians at its six clinics.

Scribes handle a wide variety of tasks formerly shouldered by clinicians during patient consultations: they document symptoms, type up diagnoses, order lab work or diagnostics, print out patient education material, and inform nurses electronically of follow-up tasks such as immunizations.

During the four-month pilot study, 36% of patients said they were “more satisfied” with their office visit; nine out of 10 weren’t concerned about having another person in the room.

“They’re so happy the doctor can look at them while the scribe can type,” says Dr. Ann Murphy, who supervises the clinic’s scribe project.

“With a scribe there, a doctor can spend a lot more quality time with a patient,” agrees scribe Rebecca Ewert.

As Dr. Laurence Heard consults with a middle-aged patient suffering from a slew of chronic health problems, scribe Tabitha Manteiga sits silently in the corner of the room focused intently on her computer screen. As the patient rattles off her concerns, Heard engages her openly, becoming more direct when discussing the options for her nagging thyroid problem, including radiation and removal.

Manteiga is locked onto the screen, typing swiftly, allowing Heard full contact with the patient. He stops only once to slide next to Manteiga, offering her clarity on a note.

Later, Heard describes how electronic health records adversely affected the patient relationship: “Imagine having to inform someone they have cancer while typing into the screen.”

Without a scribe, Heard says his usual eight-hour workday typically ballooned to 10 or 11 hours.

“They paid us to type well,” he jokes. “It was very disheartening.”

For physicians, the scribe program’s success is unmistakable.

“They just love it,” says Murphy. “There’s just no question.”

Five physicians participated in the pilot program. Today, 18 of the Shasta clinic’s 30 clinicians use scribes.

Pervasive in emergency room settings and less so for specialty care, scribes are rarely seen in community clinics.

Murphy says fellow physicians were often doing a “terrible job” multitasking as doctor, typist, and biller – all squeezed into a 15-minute consultation.

Overwork among primary care physicians is well-known, with recent research showing that 27% are “burned out” with 30% threatening to quit practice within two years.

“It can be overwhelming documenting their physical problems and their psychiatric disorders,” says Murphy.

An independent report summarizing the pilot program highlighted the importance of scribes for overworked clinicians.

“Having a scribe is the difference between feeling hopeless and overwhelmed and feeling like it’s a doable job and very satisfying,” reported one physician.

At the community clinic level, SCHC was an early adopter of electronic health records in 2008. While promising improved patient care, electronic records brought with them unwelcome consequences: lost contact with patients, longer hours for physicians, and repetitive stress injuries. Many doctors – especially older ones – struggled to master the software.

“We were one of the early bleeders,” says Dean Germano, CEO for the Redding-based clinics.

For nearly two decades Murphy had been advocating for someone to assist physicians, with the clinic actually trying nurses for a short time in a similar role – unsuccessfully. The nurses were used to serving a more traditional role, and were unprepared for the new responsibilities.

“We didn’t have a clear vision how that was going to work,” admits Germano.

With the introduction of electronic health records, however, the time for scribes had arrived. And the clinic now found the right people for the job: recent college graduates, all of them bright, some with previous experience in medical terminology. When lead scribe Michaela Mangas returned to Redding after performing a similar role in the Bay Area, the puzzle was complete.

Of the five clinicians using scribes during the pilot period, physicians noted a most significant increase in their “ability to listen.” Satisfaction was also high for “accuracy of notes” and “time spent on notes.”

“Scribes are not supposed to be seen or heard,” says Evan Boullie. “We’re supposed to be a fly on the wall.”

Yet Murphy says that the scribes become a critical support system for the doctors – both medically and emotionally.

They become familiar with doctor habits, and are a second set of eyes during patient encounters to improve accuracy.

They also offer help during emotional cases.

Scribe Lori Rodrigues recalls the appointment with an eight-year old girl with genital herpes, and how emotional her physician – a father – became during the session.

“I don’t think he would have done as well without me in the room,” she says.

“The scribe tends to calm the physician down,” says Murphy. “I’ve seen it.”

The camaraderie that develops between doctor and scribe is often crucial to the team’s success.

“One of the biggest things about being a scribe is finding your niche with them,” says Manteiga. “You have to be very good with people. You have to gain that doctor’s trust.”

“I’ve found it’s very, very important to form a scribe-clinician team right off the bat,” says Murphy. “It’s best not to rotate around with different doctors.”

A surprising discovery during the pilot program was that patients often revealed more personal information to their doctors.

One patient revealed his erectile dysfunction to Murphy for the first time while two other women joined her in the examination room: her scribe and a scribe-in-training.

In only a handful of cases were scribes – male or female – asked to leave the room by patients.

Max Finch, who works with a female clinician, says this may happen before a woman’s health examination or for patients suffering from depression. Typically it occurs with younger female patients closer to his age, 22.

“They glare at me when I come in the room,” says Finch, who will step behind the examination room curtain during reproductive examinations – especially the highly sensitive pap smear. “I’ve never been in the room for a whole women’s health exam.”

Overwhelmingly, though, patients have accepted SCHC scribes without question.

Selling doctors on the scribe concept wasn’t always easy. But the more fellow peers championed the scribes, the easier it became.

Murphy recalls one especially difficult doctor. After seeing how much easier his work load became “he fell like a big oak tree,” she jokes. Another doctor even laughed gleefully on his way to the bathroom: “See! I can pee and document at the same time!”

Still, one SCHC doctor remains a hold out, preferring to go it alone.

“I think she was really reluctant to give up control,” says Charles Kitzman, chief information officer for SCHC.

Earning $13 an hour, the scribes paid for themselves. With scribes at their side, doctors can work more quickly and see more patients. During the four-month study period, the clinic earned $7,000 more per physician while paying each scribe $5,000.

Because clinicians are paid hourly, says Germano, shorter days for the physicians are most cost-effective for the clinic.

Most important for clinic administrators: Doctors using scribes say they will stay at the clinic and practice medicine longer.

“They feel good about their day,” says Germano, “and can spend time with their family.”

Peers tell Murphy they plan to practice medicine 5-10 years longer because of their scribes.

Clinic officials hope to expand this throughout the clinical staff, but are still taking it slowly.

“What’s driving them is peer endorsement,” says Kitzman.

The pilot program was paid for by the Blue Shield of California Foundation – the first grant ever made by the foundation to a community health center to “support innovation.”

Training for scribes can last 3-5 weeks. The biggest hurdle for a generation raised on computers: “Spelling,” laments Murphy.

Scribes are asked for a two-year commitment at the clinic.

Most gratifying to scribes is knowing that they are making a difference in the lives of low-income patients.

“I know the quality of care is better,” says scribe Raechel Boys. “I can see it.”

Of the 15 current SCHC scribes, 10 plan to pursue further education in medicine.

“The last 18 months my whole life has been trying to help people,” says Boullie. “And I want to keep doing that.”

Murphy says the success of the scribe program has been nearly universal and offers this advice to other clinical sites considering their use.

“It’s really stupid not to.”

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