For the mighty Navy Corpsmen, past, current and future.
Ramblings of an Emergency Physician in Texas
unless it’s the tail rotor. They will straight up kill you.
I had the good fortune to visit the Museum of 1990s Trauma Care over the past two days. It's called #ATLS. Fascinating historic artifacts.
— Bill Hinckley (@UCAirCareDoc) December 5, 2014
A modern parable.
RICHARD GUNDERMAN, MD
Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.
Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.
Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.
That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”
I’ve written about scribes in the ED before (here’s one from 2007) and continue to utilize their services. Did I say utilize? Wrong thought: enjoy and marvel in their help is more my experience. I’m spurred to extoll their virtues and my experience after reading “Attack of the Scribes” by the great twitterer @SkepticScalpel (he also blogs at SkepticalScalpel.blogspot.com ).
Read the article, it’s well written though more than a touch odd; why’s a doc who’s never worked with scribes editorializing on their pluses and minuses? The literature review is fair, and there probably isn’t enough scholarship on the issue of whether scribes can have a measurable impact on physician productivity. I think we’ve only scratched the surface with scribing in the hospital, as I think every nurse should have a scribe. Imagine, nurses nursing rather than staring at screens, checking boxes! It would be hugely liberating for them.
I’m going to insert some quotes from the article then answer them:
“The emergence of the electronic medical record (EMR) has spawned a new occupation—the scribe.”
No, scribes have been around since ink and paper, and maybe before. I would accept that the EMR has spawned a new medical occupation, though we used scribes in the paper chart world before the EMR. It is certainly true the EMR has facilitated the explosion of scribe utilization (and companies to fill that need).
“I have no personal experience with scribes, but I suspect their notes would tend to be too long rather than too short. Do we really need longer notes in charts? No. Residents need to learn how to write concise progress notes that do not duplicate what is already in the chart. This would require a culture shift by faculty and senior residents who tend to expect voluminous notes.”
Scribes document something like doctors without scribes: all over the map for volume. Some distill the history in a few sentences, some type verbatim, and there’s a mixture between. In the ED, as the note is pretty heavily templated, and so much fluff and junk are automatically stuck in there, an extra sentence or three isn’t contributing to note bloat. I would never scribe any other than a Senior resident, as learning what and how to document is part of the education.
Additionally, docs 40 and above didn’t grow up with keyboards like our scribes did; that means less information added by poor typists, which isn’t good for the patient or the documentation.
“The presence of a third party during the doctor-patient interaction has not been an issue so far, but it is conceivable that some patients might feel uncomfortable.”
I’ve had one patient ask the scribe to leave the room. I introduce myself, introduce the scribe as ‘my assistant’, and it’s not an issue otherwise. (We do excuse them for the more intimate exams).
“When a scribe enters a note in an EMR, it must be cosigned by the physician. Experience with dictated H&Ps, notes, and operative reports shows that most of these entries are not carefully proofread before they are signed. Using scribes opens up new vistas for plaintiffs’ attorneys if patients experience bad outcomes.”
I disagree; the issue is the quality of the documentation, and it’s irrelevant who pushes the keys. The name at the bottom of the chart is responsible for the content. Before Texas’ Prop 12 several of us were sued, and the use of scribes never came up as a problem in depositions or trials.
“True story. I know someone who had pain in her arms. The scribe documented the doctor as saying “consider a mass” instead of what he actually said, “consider MS.””
Professional transcriptionists get words wrong frequently, and the speech-to-text used by our radiologists is often inadvertently hysterical (‘Sono: Renal and Nasal’ was a recent report header), so communication errors happen. That’s why we read and edit charts.
I don’t need a study to tell me scribes make me more efficient, but we did one anyway. We were very efficient on paper charts, with scribes, and the EMR showed up. We went through the training, and had people time scribe-on-paper vs the EMR for time; the EMR was tremendously slower (40% more time required), which was a big hit in an efficient system. We’ve gotten better, but several of our docs use two scribes to get their speed back (and more; I now see more per hour than I did on paper). We didn’t publish our data. Maybe we should have.
Our scribe company* has gotten a whole lot bigger, and a lot more corporate for better and worse. They turn out trained and enthusiastic scribes, and they’re still wonderful to work with. I showed up very early for work the other day and decided to start early, which reinforced that I can manage the EMR and do my own documentation, and I’m terrifically glad I don’t have to.
Dr. Henry has also been quoted (though I cannot find it) as saying ‘the ER doctor should be a free floating brain’, meaning let the doctor do the thinking they’re trained to do and let anything that not that be done by someone else. It makes zero sense for the highest compensated in the department to be the typist (not a slam on typists, it’s about the best use of time and talents).
Scribes. If you use an EMR, or don’t, get them. They’ll make you money, and they’ll make your day way, way better.
*Full disclosure: I independently contract with a CMG that supported and then spun off our scribe company. I’m also friends with the scribe company senior management, and they’re good folks. I’d say nice things about our scribes if none of that were true, but don’t want my relationship to be an issue.
Which is terrible, yet predictable.
ACEP Now | The Official Voice of Emergency Medicine.
Yeah, it’s completely devoid of interviews or conversations with the purported future leaders of Emergency Medicine.
Again, if you’re running for President of ACEP but abide by the Gag Order, you aren’t worthy, and we (as a specialty) shouldn’t support them.
Posted by Ryan Radecki
It’s been 5 years since the last Cochrane Review synthesizing the evidence regarding tPA in acute ischemic stroke. Clearly, given such a time span, in an area of active clinical controversy, a great deal of new, important, randomized evidence has been generated!Or, sadly, the only new evidence available to inform practice is IST-3 – a study failing to demonstrate benefit, despite its pro-tPA flaws and biases. So, it ought not be a very exciting update, considering the 2009 version included 26 trials, and the 2014 update now includes only 27 trials. Their summary conclusion, with only additional evidence of regression to the mean, ought remain essentially the same, or even less optimistic, right?
Of course not:
Read, and enjoy. Excellent analysis.
A fisking of a paranoid, ill-considered and frankly stupid idea a 9th grader would be ashamed to put forth. From the American College of Emergency Physicians ‘leadership’.
By James M. Cusick, MD, FACEP
Chair, Candidate Forum Subcommittee of the ACEP Council
ACEP is a member-driven organization with a representative body of our peers – the ACEP Council – chosen through component bodies, including our chapters (1 representative per 100 members), our Sections of Membership, and other aligned organizations.
There follows some boilerplate language designed to get you to tune out.
None of this is aimed at the author, BTW, I have no doubt he was asked to write this and didn’t make this decision. This is about the College and a terrible decision that reflects poorly on it.
In addition, protections were incorporated into the rules to keep candidate interviews in ACEP publications. Our goal is to avoid candidates being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates.
Wait, what? Candidate interviews for ACEP positions can only be in ACEP house organs? Is Stalin in charge? And for the rationale of “…being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates” means ‘we intend to cover up for the candidates we really want to win, and the gaffes from the unworthy will be published in bold print, but rest assured if you’re our selection it’ll totally be glossed or even left out’.
Count on that. And that’s bollocks.
It’s the biggest horse shit this college has dumped in quite a while, and that isn’t how I want my college to represent itself because that’s how it represents me. Really, if you’re running for President of ACEP, you should be able to handle a non-coddled interview. Seriously, you’re going to say they’re too fragile to be interviewed ‘without adequate preparation…’ and then expect them to deal with legislators and their staffs who are dealing with skilled negotiators and people who know what they are there for? No thanks, I’d rather know the warts and all right up front, not filtered through the ACEP info-seive.
Certain candidates may unfairly benefit from coverage in non-ACEP publications, while some may be disadvantaged. In order to ensure a fair election, campaign questions and the vetting of candidates is the responsibility of ACEP, its Council and its Council Committees.
Umm, no, it’s the right of all of ACEP to know who’s running for office, what their unfiltered views are, and how they handle themselves with tough questions from tough questioners. It’s called campaigning, it’s not the pinewood derby. The very idea that ACEP can make an election totes fair by limiting the questions and answers to their own publications is laughable, were it not so tragically and pathetically sad. If you’re worried someone has an unfair advantage, Editorialize in ACEP Now, and their 150 avid readers can spread the word. But this entire approach is insulting to the intelligence and spirit of ER docs in our great nation.
(Any of you ER docs want to make sure your patients are only presented one at a time, with discreet illnesses and injuries, with a pre-selected choice card of correct diagnoses? No? It’s because we live and work in the real world, and that’s an absurd proposition, like this).
Also, and some may not be aware, but this is most likely a reaction to the excellent challenge by Dr. Greg Henry, ACEP Past-President and fixture asking for a robust questioning in his April 28, 2014 article ACEP, let’s set a real agenda. Read that article, and the kind of questions he wanted to ask, then you’ll see this in-house gag order for what it is: cover for their chosen.
If you’re a candidate for president and you buy into these rules, I know you’re not ready for the job.
If there are specific questions you would like asked of the candidates prior to the election, please send them to email@example.com. The Candidate Forum Subcommittee will consider them, the selected questions will be posed to candidates and their responses will be made public.
Really. You’re not only going to vet the answers and decide what goes out you’re going to control the questions, too? Here are a couple for you: a) boxers or briefs, and b) puppies or kittens?
I for one would like to have someone bathed in the knowledge of fights won and lost ask our presidential candidates hard questions about the tough choices facing ACEP, but we will absolutely not get it with this format. On purpose.
Hell, we’ll be lucky to find out if they like puppies.
Colleagues I can call on and count on.
Recently I was the 11p doc in my ED (the overnight shift), and I knew what my evening had in store when Colleague/suspect1 said “It’s been slow all day”. Oy.
At 11:03P the charge nurse (who deserves a Medal for her actions that night) said ‘you’re getting a level 1 medical and two level 1 trauma transfers in the next five minutes’, and that was in addition to the waterfall of regular patients who heard the word ‘slow’ and ran like very sick possessed zombies to our ED.
The medical was a great case I would have loved had I had no other duties: CHB, external pacer dependent, and I did the right thing for this patient: I called the procedure doc, and turned that patient’s care over to him (
the one who caused this, Colleague1). (I knew what this patient needed, it’s an intubation/cordis/float the pacer/etc, and that’s 20 minutes straight of terrific procedures while letting the department drown). He did as well as you’d think. Maybe better than I would have done.
The other colleague star was Golleague2, the 9P, who never peeped that I wasn’t sending him home, or really even taking his workups. In fact, toward the end of the night he did a lac or two for me, and I kept Colleague1 busy until 3 with procedures. Terrific to have people you can count on.
This isn’t about me, or even these two great colleagues (though I thank both of you profusely), it’s really about all of us. Giving means getting, and I and our mutual patients got the best that night, and get it when we work and play well together.
It’s a great place to work. Thanks to you all.
If your driver has a personality disorder, it will reflect on you. It’s unavoidable.
please ask them to wait for you in the waiting room. Or in the car. Or on Venus.
(EMS not included).
For the record, I’m all for this, providing it pans out in trials…
PITTSBURGH — Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.
Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity, the patients will be clinically dead.
And then the surgeons will try to save their lives.
Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery — and, some say, medical ethics.
By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims’ wounds.
Some of the country’s best doctors have the worst patient satisfaction scores. Here’s why.Part of being a doctor is learning to suppress your feelings. You get good at being what people need you to be. But it slowly transforms you into something you couldn’t have foreseen—a sort of Stepford doctor—pleasing everyone with your perfect smile and agreeable demeanor, hoping that your patient satisfaction survey will be favorable, no matter the cost.
Press Ganey is one of the top providers of patient satisfaction surveys, according to the Forbes article, Why Rating Your Doctor Is Bad For Your Health.The government has bet big on these surveys, as a recent article in Forbesnotes. Armed with the idea that “patient is always right,” Washington figured that more customer satisfaction data “will improve quality of care and reduce costs.”
That turns out to have been a bad bet.
Read the whole thing, but it’s what your doctors, especially the hospital based ones, have been saying since day 1.
You don’t say.
Market share and prices tend to climb among hospitals that employ doctors but not for hospitals with looser contracts with independent physicians, according to newly published research. The findings, the authors say, suggest that integration itself does not produce the savings that many health system executives and policymakers promise from closer coordination between hospitals and doctors.
Hospital prices, according to the study, increased 2% to 3% each time physician-employing hospitals’ market share increased by one standard-deviation. The results were drawn from an analysis of roughly 2 million hospital bills submitted to private insurers between 2001 and 2007. Overall spending on services at the hospitals that employed physicians grew, while the utilization of services at those hospitals didn’t change.
Many thanks to Steve in the comments on the last post for alerting me to this movement:
It’s time all clinical trial results are reported.
Patients, researchers, pharmacists, doctors and regulators everywhere will benefit from publication of clinical trial results. Wherever you are in the world please sign the petition:
Thousands of clinical trials have not reported their results; some have not even been registered.
Information on what was done and what was found in these trials could be lost forever to doctors and researchers, leading to bad treatment decisions, missed opportunities for good medicine, and trials being repeated.
All trials past and present should be registered, and the full methods and the results reported.
We call on governments, regulators and research bodies to implement measures to achieve this.
I signed the petition, and hope others will as well.
Realistically, this will require either a mindboggling scandal (even worse than the ones we know about) leading to group self-regulation, or more likely, intrusive and poorly thought out legislation.
I know what I’d bet on.
Hint: Roche stinks, and the Cochrane Collaboration has done all of us a huge favor. Time to stop prescribing Tamiflu.
What the Tamiflu saga tells us about drug trials and big pharmaWe now know the government’s Tamiflu stockpile wouldn’t have done us much good in the event of a flu epidemic. But the secrecy surrounding clinical trials means there’s a lot we don’t know about other medicines we take