Scribe Value in Easing Burnout Is an Ongoing Debate

Linda Bosserman, MD

Linda Bosserman, MD, went on vacation recently with what she considered to be 50 hours of transcribing and other administrative work related to her oncology practice. She routinely puts in hours of work on documentation each night.

Bosserman thinks that having a medical scribe working alongside her each day, helping with the note-taking and computer entry portions of her job, would be ideal, except for the fact that she doesn’t believe medical scribes have enough training or capability to relieve oncologists of the type of complex documentation tasks they have to do.

Bosserman, a medical oncologist at City of Hope in Rancho Cucamonga in Southern California, believes that she’s not alone in her opinion. Based on her interactions with other doctors, she believes that scribes are rarely if ever used in the oncology profession. “The challenge in oncology is we’re trying to personalize cancer care with multiple cancers, multiple different stages, tumor types, and now this explosion of molecular diagnostics. That’s a huge amount of data you’ve got to pull together for every patient to figure out what the right treatment is and what their side effect management is. It’s hard to train people to know that much,” Bosserman says.

Bosserman, an efficiency expert who has served on numerous medical boards and committees and is a founding member of the Community Oncology Alliance, says scribes are becoming more commonplace in other areas of medicine. Scribes are becoming integral in emergency departments, and primary care doctors are reaping huge efficiency benefits by employing them, she says.

But oncologists can only stand by wistfully as their documentation needs grow and current electronic health record technology remains inadequate to the task of easing the workload, Bosserman says.

This worries her, as it indicates that oncologists have no source of relief, and that the profession is up against a serious problem: workplace overload.

“Burnout is associated with doing nonproductive work, administrative burden, authorizations, pre-authorizations, and notes,” she says. “The challenge in oncology is that you’re one-on-one with very sick patients, making decisions, and then you’ve got to go and capture all of this.”

Michael Murphy, MD

Michael Murphy, MD, CEO of ScribeAmerica, takes exception to Bosserman’s view that scribes have not penetrated the oncology profession and are not capable of working with the complex data that have to be recorded. Founded in 2004, ScribeAmerica has seen huge organic growth as well as growth through acquisition. The group now employs 7300 scribes across the United States in 950 hospitals and other health centers, according to Murphy. While ScribeAmerica would not indicate how many of those scribes are employed by oncology practices, Murphy contends the use of scribes in oncology has been roughly similar to that in other medical branches.

“I can’t really tell you the ratio of [oncology] growth compared with other specialties,” Murphy says. “All of the specialties seem to be growing pretty dramatically over the last few years, but we’re with some of the largest oncology groups in the country—Texas Oncology, 21st Century Oncology. These are some of the behemoths around the country, and then we’re with a lot of other, small hematology/oncology practices that are private or within big medical groups. So, it’s probably been the same pace as the other specialties of growth,” he says.

The biggest growth in scribe employment has been in the urology, cardiology, and orthopedics lines, Murphy says, while endocrinology has been slow to develop due to the high complexity of the field. “Most of the time their [patient] visits are a half hour or longer, and sometimes they just can’t really see more patients because they’re spending so much time trying to figure out the different pathways.” The same documentation needs that have plagued the oncology profession are contributing to the rising use of scribes across the board, Murphy says, echoing Bosserman’s sense that burnout is one chief reason physicians would turn to scribes if they could. “The physicians, when they come to us, they’ve just about had it and they’re ready to hang it up. They’re frustrated, they’re really just angry and just burned out,” Murphy says.

Murphy estimates that scribes in his employ get about a month’s training before they are considered fully ready for working in a practice. There is some follow-up training included, he says. Speaking in general terms, not specifically about oncology practices, Murphy says that having scribes working one-on-one with them enables physicians to see from 5 to 8 more patients per day, and that physicians can cover the cost of scribes by seeing just 2 extra patients a day.

“A scribe is there to do everything in real time, in parallel, not only the exam, the visit, the documentation, but also help you with the ICD codes, the follow-up care, and the scheduling of appointments. A scribe is a true definition of a lean process. From what we’ve seen, if the physicians have had a productivity loss, we got that back plus an incremental number,” Murphy says.

But a month of training and a bit of follow-up instruction is not nearly enough, says Bosserman. “Sometimes my nurse practitioner and I will go in on a really complicated person together, and she’ll scribe the note while I’m talking to the patient. But that’s not a good use of a nurse practitioner’s time, because they’re highly trained clinicians.”

Bosserman believes the solution to rising administrative workloads is going to have to come from somewhere else. Whoever does solve the problem is likely to capture the best and the brightest among the oncologist population, she says, which makes it an issue of business survival too.

“Whoever develops more supportive electronic medical records and more supportive methodologies will be able to hire the best people,” she says. “That’s what they go to work to do—perform high level analytics, and then assess and educate patients and engage them in the best healthcare for their needs.”

Punit Chadha, MD

However, Dr. Punit Chadha, medical oncologist and hematologist with Texas Oncology in Austin, Texas, is an example of an oncologist who does use scribes, and he says the payoff has been many hours of saved labor and much more time with patients. He began using scribes 8 months ago and now has several working in his practice.

“Patients are my first priority,” Chadha says. “I started using a scribe so that I could spend more face-to-face time with each patient and not be staring at a computer screen during each visit. The scribe allows for real-time transcription so that the note is in the chart and is sent to the referring physician much sooner than if it had been dictated.”

Chadha also personally checks a lot of their work to make sure it is reliable, he says.

“The scribe works side by side with me to document each patient visit. He or she comes in the exam room with a laptop during each visit. I introduce the patient and the scribe to each other and confirm that the patient is OK with having the scribe in the exam room, and then we carry on with the visit. The end result is that a progress note is completed in real time and ready for me to review immediately after each visit.”

Chadha says that he supplements the training scribes receive prior to joining his practice by having them work closely with the physicians on-site.

“Each scribe has training in clinic flow, medical terminology specific to hematology and oncology, physical exam findings, documentation, billing, meaningful use, and pathophysiology related to oncology prior to coming on-site,” Chadha says. “Once onsite, it takes 1 to 2 months for the scribe to learn the physician’s style. Depending on the background of the scribe, it also takes several months to gain a solid understanding of the hematology/oncology world from a scribe’s perspective. There are limitations to what a scribe can do. They are not allowed to take or enter medical orders in our electronic medical record, touch patients, etc. All scribe tasks are done at the direction of the physician. Their primary role is to work side by side with the physician to record each patient visit.”

Aside from the debate over the effectiveness of scribes in the oncology profession, a report in JAMA earlier this year raised the issue of the general capability of scribes, along with serious concerns about whether they would be susceptible to manipulation by physicians who asked them to do order entry.

“Another risk is unintentional or intentional functional creep in how medical scribes are used,” the report stated. “Although the Joint Commission prohibition on use of scribes for order entry is unequivocal, some physicians still advocate use of medical scribes for computerized physician order entry. The Joint Commission cannot monitor whether medical scribes are used for order entry by US physicians. Patients rely on physicians to understand what constitutes unsafe use of technology in delivering healthcare, including clinical information technology.”¹

Chadha says scribes in his practice do not assume tasks above their station. He describes them as “incredibly valuable.” “Although some might say that using a scribe provides a mechanism for physicians to become more disconnected from the medical record, having a scribe actually gives me more time to review notes and patient records. I review each patient note prior to it becoming a part of the chart as I’ve always done,” he says.

1. Gellert G, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records. JAMA. 2015;313(13):1315-1316. http://jama.jamanetwork.com/article.aspx?articleid=2084910. Accessed July 17, 2015.