Behold, a very worthy rant. Recommended.
I frequently order from you (check my records, I’m not exaggerating). I’m giving you this feedback just as the Christmas shopping season starts to help you, not out of spite.
First, had I wanted USPS to deliver my packages I’d order from someone other than a class act like Amazon. So, please don’t use an organization that’s dying for a reason (inability to get the job done).
Second, if you’re going to use USPS (and see #1, you shouldn’t), please don’t ask for a signature on a $50 order. UPS and FedEx know us quite well, and know our neighborhood is remote and really really safe, so they know where the packages should be placed/hidden. USPS apparently doesn’t.
In fact, they have failed to deliver my package twice now, twice sending me an email that they left me a note (they didn’t) and telling me when they tried (when we were home, both times). Getting the picture? USPS isn’t reliable, or trustworthy. So stop trusting them with our business.
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.
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.
Our Government is out of money. That’s given. Related but unrelated, our Government=Things we do together.
The Army Corps of Engineers recently decided that plowing Govt. Park access fees back into the parks through non-profits is verboten, because, get this, the money isn’t going into the US Treasury.
No thought to what makes the parks work. No thought to what the NonProfits (that’s Washington for sucker-bait) put into the parks, or what the Federal version of park running and maintenance will cost (that’ll be way way more than non-profits did it for). Or the park non-profit employees who are now out of a job.
This smacks of bureaucracy run amok, remote pencil pushers running roughshod over local policies that actually serve the constituents, i.e., normal people who like parks.
I’ll call my Congressperson tomorrow. Perhaps sense will prevail, but I have doubts.
Now, about that Government takeover of healthcare, still think that’s a terrific idea?
U.S. intelligence mining data from nine U.S. Internet companies in broad secret program – The Washington Post
Thank goodness my blog’s not on this list!
U.S. intelligence mining data from nine U.S. Internet companies in broad secret program
Forgive the levity. Privacy, schmivacy. It’s not like the Government will ever use any of this for partisan purposes.
The other day my lovely wife bought a Ford. It’s nice. (They sold her a car that’d already been sold; then made up for it by giving her a car with more options than the one she originally tried to buy and eating the difference. Thanks Ford!).
While she was
beating the dealer until they cried negotiating I looked at the other show-room vehicles. And I found the Ford Mustang (genes and all).
I was thinking Steve McQueen, and Bullitt. Really.
The drivers’ door wouldn’t close (on the showroom floor) and then I saw the dash:
I get marketing. You want to sell this car as a True Sports Car with a lot of Speed!!! Here’s the thing: as my eyes slowly age I don’t want to have to squint at the 1/2 inch to discern the difference between 35 and 45 while knowing this bad boy won’t go over 160, and never near 220. I don’t need a big HUD to tell me, but this display is just dumb.
a guy who’d buy a Mustang but not one with this silly detail in it.
Been a while since I pulled out the BS flag, and this seems entirely appropriate:
Good doctors really do feel their patients’ pain.
Hmm. ‘Good’ doctors?
A study, published today (Jan. 29) in the journal Molecular Psychiatry, shows that when doctors see their patients experiencing pain, the pain centers in the physicians’ own brains light up. And when the doctors give treatment to relieve pain, it activates the physicians’ reward centers.
The doctors were then instructed either to use an electronic device that they believed would relieve the patients’ pain, or to withhold the pain relief. In response, the patient-actors either grimaced in pain or maintained a neutral expression to suggest their pain had subsided.
Umm, what? These ‘good’ doctors were told that an electronic device would either relieve or not relieve pain, and then they reacted to their patients’ acting with activity in their own pain or reward centers by fMRI.
My first question: did these docs really buy into this magical electronic pain-relieving device, and if so, why? I have to wonder if it was their amusement areas lighting up and not their pleasure centers…
Second, at no time is ‘good’ established in this article. Were there a subset of docs whose fMRI’s didn’t change, and thus they’re ‘bad’?
Not buying it (would buy one of those magical electronic pain relievers, though).
*I say this is a BS study based on this writeup. If it’s something else entirely, okay, but this is just awful.
This is kinda political, and as you shouldn’t give a fig about what I think of politics, please skip it. I’m doing it a) to vent my spleen about a stupid Congressional stunt and to show that I’d rather call out conservatives who behave badly than fill my blog with finger pointing that “they’re the problem” while remaining deathly quiet when their side screws up.
(I’m sorta little L libertarian, mostly, and will never be electable as I’m ‘a little for a, a little from b’ in my political leanings).
So a REPUBLICAN Congressman (Ohio) is afraid of bad publicity at a Town Hall meeting, so he gets the Cops to do his official suppression and intimidation, and they then did it!?
Talk about someone you shouldn’t buy a used car from, let alone vote for. Imperious behavior tells you everything you need to know about what he thinks of his constituents.
(I don’t live in OH, and won’t get the chance to vote against this idiot, but if you’re in his district it’d be worth the effort to have him thrown out).
August 23, 2011 @ 9:39PM
Ohio Congressman Has Cops Confiscate Cameras At Town Hall Meeting
Steve Chabot had two cameras confiscated in public meeting
By Carlos Miller -…
Hoping to prevent an embarrassing Youtube video from making the rounds, Republican Congressman Steve Chabot of Ohio ordered police to confiscate cameras from people attending a town hall meeting Monday night.
The result was two embarrassing Youtube videos that are sure to make the rounds.
The first video shows a police officer confiscating a video camera from a woman in the audience as television news videographers record the interaction.
The second video shows a police officer confiscating a man’s iPhone as it recorded, capturing the dialogue between the two.
The cop tells the man that he is not allowed to record the event “to protect the constituents.”
Meanwhile, televisions news crews were videotaping openly.
Also note, now this idiot has videos that show the cops grabbing cameras, which is way, way worse than anything a Think Progress noodlehead could come up with in a YouTube rant. We fully expect nonsensical behavior from them, not official suppression and intimidation from an elected official. Thanks for proving the noodleheads’ point.
Rant follows the pull quote here:
The National Rifle Association and other gun rights groups had pushed for a much stronger bill that would have precluded doctors, in many cases, from asking patients about whether they own guns. Backers of the measure, sponsored by Sen. Greg Evers, R-Baker, had said patients were being harassed over gun ownership.
But citing the confidentiality of what is said between doctors and patients, and a broader desire to protect other members of patients’ families, doctors had pushed back hard against the bill (SB 432). The issue had promised a fight between two of the most powerful lobbies at the Florida Capitol.
But an amendment adopted before the committee’s vote on Monday would now generally allow doctors to ask questions about gun ownership, as long as the physician doesn’t “harass” the patient, and doesn’t enter the information into the patient’s record without a good reason. That leaves enough room that doctors now support the measure, as does the NRA.
Nobody should support this bill. I’ve said so before. And to remind everyone, I’m a doctor who owns a gun.
Your doctor harasses you about guns? Stand up, walk out, get another doctor. Tell your shooting friends to avoid that doc. That’s fine. Look, if you own a gun, ostensibly for self defense, but cannot say ‘no’ to a question you think is out of bounds you need to sell your gun. Use the money to buy a sign that says “Please don’t hurt me, I’m unarmed (and don’t ask me questions in an offensive manner either)”.
What kind of sissies live in Florida that if their doctor ‘harasses’ them about guns they need a law affecting all doctors in their state so they don’t have to say ‘none of ya beezwax’? Really, this rose to the level of insult to the patient population that legislation was required? This is where our Republic is, we need to regulate speech so nobody gets offended?
Nothing good will come of this special interest encroachment into what can be discussed in a physician patient relationship. This sets a terrible precedent going forward. ‘Well, it was okay to ban conversations about guns, so now the (insert special interest group) manufacturers have this bill, see, and…’.
Shame on the Florida docs for agreeing to this travesty. Opposing this, and taking it to court had it passed, would have been the right thing to do. For your profession, your patients, and your country.
This is going to sound awful, but… if you kill yourself you’re obligated not to take others with you. I know that people who kill themselves aren’t thinking about others, but, here’s a cautionary tale:
Bullet from suicide try ends up in Starbucks
GRAPEVINE — A Starbucks customer stirring his drink Thursday afternoon heard a bullet whiz by his ear after a man shot himself across the street from the coffee shop, police said. The man was on the front porch of his house in the 900 block of East Wall Street, said Lt. Todd Dearing, a Grapevine police spokesman. The bullet went through the man’s head and the drive-through window at Starbucks and past the customer and finally lodged in a restroom wall at the back of the business, Dearing said. The man who shot himself was taken to …a hospital…
Bold by me.
Rifle? Crazy high powered pistol firing a very solid bullet? I doubt we’ll ever know, but it’s a cautionary tale. Extremely fortunate that round didn’t collect an innocent soul.
How to kill the space program: Satellites to issue speeding tickets from space – SciTechBlog – CNN.com Blogs
UK drivers had better stay under that speed limit, because the traffic authorities are watching… from outer space. According to The Telegraph, an American company called PIPS Technology has developed a system that uses two cameras on the ground and one mounted on a satellite in orbit to catch speeders.
This is entirely feasible now, with toll tags and the like. Wisely, I think they’d rather have the tolls than a few fines and empty roads.
Putting big heavy snoopers into space is very very expensive, and totally optional. Use an optional program against a populace (even one that’s guilty) is a really good way to get that one, and its more useful cousins, unfunded.
That, and a very gradual change in how I currently see this blog, and myself.
I’m enjoying my new shooting hobby, but haven’t inflicted the horrific paper-target carnage on you, gentle readers. The tales of tiny holes in paper would cause most to blanch, and I’m not callous enough to inflict those stories on you. (I have had an influence on a colleague or two, and now there are more shooters in my ED than many, I’d wager…) (At least one can repeatedly hit a target 1K yds away. Whee!).
Professionally, I’m on-plane: the learning curve is mostly behind me, and now I’m in ‘practice mode': do the best I can for each patient, get enjoyment from it whenever it happens. No, my profession isn’t about being entertained, but the job is sometimes more task than enjoyment. (Just like your job).
I’ve been Officially Instructed to stop being cranky at work, so Happy! (or not unhappy!) is the Rule of the Day. I get it, and hope nobody has taken my taciturn manner personally. (If you have, it’s not personal: tell me face to face if I’ve crossed you and I’ll tell you we’re fine, and that it’s me, not you, and mean it).
Current macro medical politics makes me so crazily unhappy I dare not commit my thoughts to blog, so I’m waiting for the right vehicle to which to add my thought(s). So, silence there.
Interestingly, the Readers Digest article (March, 2010) has resulted in more unhinged hate-mail than I’ve gotten in a good while, and I’m intrigued by the black/white should/shouldn’t a few people have about docs and health care professionals in general. The idea that those employed in health care aren’t robots without experience or opinion (let alone judgment) seems too shocking for these naifs. (Those who are shocked! Shocked! are also pretty profane, making the average Borderline Personality look like a piker…). Ahh, well. Such is fame.
And, to the Sloth. I’m not an original writing blogger (a few posts to the contrary); my limited strength typically falls in commenting on others’ ideas, and pointing out strengths and weaknesses. This makes me an unoriginal blogger, which I get. Yet I persevere, or at least don’t quit.
Not ready to quit yet, by a long shot. Blog maturation, or senility? We shall see.
Yeah, dumb pun: the article was sent to me by a dentist…
It’s a short post, so I grabbed it all (go read his, though, for the links to the source material, and to read a good blog by a Navy Dentist).
New Jersey Assembly Bill , A.B. 4175, introduced on 23 November 2009 will require physicians, dentists, and nurses to complete 30 hours of volunteer service in their respective fields as a condition for biennial registration.
Well…..Guess what New Jersey? This is the final straw. You just lost another provider. Happy? Whose going to treat all those folks with insurance now?
So, this is one of those weird times where those potentially affected say ?wha? Is there some pressing reason to command volunteerism in order to be licensed?
I’d be willing to bet you could find a few people in every medical profession who think they must never treat anyone for free, and barring some scheme like that proposed in NJ, they’d be legally right. Morally, I don’t know.
This is one of the reasons EMTALA is widely derided in the emergency department world: the difference between generosity, giving your time and talent without expectation of reimbursement when it’s needed and you’re able , and State coercion, the taking of your time and talents whether you consent or not.
(“You can stop taking Medicare or quit your job” you say, and while the second is correct the first is not, as I’m hospital based and required to accept Medicare, and the strings attached). Also, it’s quite a thing to be expected to quit ones’ job to avoid having my work literally taken from me by governmental fiat (thanks, Pete Stark).
I wonder what the NJ medical, nursing and dental societies thought of this? I’d bet if they made a public statement it was at least mildly supportive (imagine saying “no”, and being pursued by some idiot with a camera and a mic yelling “don’t you care about the children?”).
For some reason if your job is thought of as one of compassion many people, governments included, expect you to be willing to do it for free. I don’t get that.
(An aside for those of you with business outside medicine: you can write off bad / uncollectable debt; we can’t). (No, I don’t know why, either).
Someday medicine is going to figure out how to explain that it’s not the bad guy, that we’re giving way more than we take. And make it understandable to everyone.