Pre-med student Jennifer Termeer wasn't sure she really wanted to be a physician. After all, what lay ahead? Headlines told the story: HMO hassles, soaring malpractice premiums, mountains of paperwork.
Then a family friend, a charge nurse at Antelope Valley Hospital north of Los Angeles, proposed a solution. She asked Ms. Termeer if following an emergency physician around might help.
“That's how I met Dr. Mark Brown,” recalled Ms. Termeer. “And then, at the end of it, he turned to me, and said, ‘We have a new position starting here, and I think you'd be great for it.’”
Thus began a program at Antelope Valley Hospital that some believe will usher in a new movement for emergency departments near and far: The era of the scribe. Scribes, who start at $10 to $20 an hour, accompany physicians on patient visits, recording histories, keeping track of lab tests, and expediting discharge or admittance.
The program began when a physician at Antelope Valley heard about the concept at a medical conference and asked executives at his hospital to try it. Soon there were 12-hour shifts implemented for scribes with round-the-clock coverage.
As a result, Antelope Valley is credited with being the first one to use these new physician-extenders fully, but there are scattered reports across California and the U.S. of scribes being brought into EDs during certain shifts. Cottage Hospital in San Barbara now has a program, and so does San Gabriel Valley Medical Center.
Working alongside the physicians in the emergency department at Antelope Valley, pre-medical students and prospective nurses from nearby community colleges and a state university help take some of the burden off the busy physicians there, where the wait — once an average of eight hours — has plummeted to two or less. The center, which has one of the highest per-capita patient loads in the entire Los Angeles area, sees roughly 400 to 450 patients daily. The facility, which has a 30-bed ED, couldn't function nearly as well without the scribes, according to John Lynn, MD, the medical director of emergency services.
“I don't think we could run this place without these people,” he said.
Physicians in Training
So far, two of those scribes have gone off to medical school, and Ms. Termeer, who is finishing up her master's degree in neurophysiology at California State University, Northridge, hopes to do the same. In summing up what she does, Ms. Termeer noted that it is really a case of tracking details and “taking care of incidentals.” The patient history, for example, is something for which scribes have become responsible, but only under the purview of a physician, who checks it carefully before signing off. This has reduced the time required for the paperwork necessary to process a patient.
As Ms. Termeer sees it, there is no college-age job as psychologically or financially rewarding as the one she has been doing in the ED. Not surprisingly, she wants to be an emergency physician herself. “It is a real family in the ER,” she explained. “The doctors are so collaborative, and they are natural [teachers], always sharing information from the broad range of knowledge they have,” she said. “They are so encouraging, too, always telling us to reach for the stars.”
“I don't think we could run this place without these people.” - Dr. John Lynn
“I have been told by some who use scribes that for every dollar spent, you can generate two dollars.” - Dr. Richard Bukata
For some physicians who have utilized them, scribes appear destined to become part of a solution affecting many EDs. “I have been told by some who use scribes that for every dollar spent, you can generate two dollars,” observed W. Richard Bukata, MD, the medical director of the emergency department at San Gabriel Valley Medical Center and a clinical professor of emergency medicine at the Los Angeles County/University of Southern California Medical Center. Though scribes at his facility are currently used four days a week during peak periods, he said they are a substantially underappreciated resource that can help many other EDs.
Dr. Bukata said “physician and nurse work should be facilitated. They are the most expensive staff in the department, yet much of their time is consumed performing tasks that others could do. Nurses end up answering phones, ordering meal trays, getting blankets, bandaging minor wounds, repeating vital signs, all work that techs could do,” he said. “More techs in the ED can substantially shift a lot of the non-RN work away from nurses and allow these scarce employees to focus on tasks that only they can perform. Given that the nursing shortage isn't going to end soon, a strategy to facilitate nurse work would seem to be a viable immediate solution to the shortage, yet you don't see a lot of this happening in most EDs.”
Dr. Bukata said charting is a major time drain for physicians. If a physician sees about three patients per hour, it is likely that at least 15 minutes of each hour will be spent on charting. To the extent that much of this work could be facilitated by scribes, physician productivity could be substantially increase, he said. “You have to remember that to the extent charting on other patients prevents a physician from seeing a new patient, the true costs of charting are very high.”
Scribes start at $10 to $20 an hour, accompany physicians on patient visits, record histories, track lab tests, and expedite discharge or admittance
Dr. Bukata acknowledged that not all physicians agree. “I think if you asked some of the doctors, they might say it is not all that helpful,” he said. Why? For many there is some discomfort in using a new system or relinquishing some control of the content of the chart. For others, perhaps, they are already very efficient in their charting, and the scribes are not viewed as substantially increasing their productivity. But Dr. Bukata noted that scribes can do a lot more than just facilitate charting; they can chaperone or assist during exams, put x-rays up on the view box, get labs, make calls, and do a wide variety of other tasks to facilitate physician productivity.
Although striving for efficiency may fuel the trend, Ms. Termeer stressed that for scribes there is a lot more to gain from the ED experience than helping shorten patient waits, lessening paperwork, and making good money while paying for college.
“It is hard to bottle into words what I have gained,” she said. “You walk into an ER, and it is just going crazy, and yet you learn how to focus, how to do things you never thought you could do under so much pressure,” she said. She remembers the time when a mother brought in a sleepy little girl, and the mom was worried. The child had been with her cousins all day long and complained of being tired, but even so, seemed to drift off into a sleep from which she couldn't be aroused.
“It was late at night, and the triage nurses were so busy. But this girl, I think she was about 4 years old, she looked so lethargic. And I knew that wasn't good,” said Ms. Termeer. “So I just grabbed a doctor, which is something I felt I could do. It is such a team in the ER. I didn't know it was a drug state. But she had to spend a few days in the intensive care unit.”
As it turned out, an empty bottle of an over-the-counter sleep aid was later reported to have been discovered. “So, when I am asked what I have gained by working here, in the ER, I think the better question is ‘What have I not gained?’” Ms. Termeer said.