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EMIM2011

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Does anyone know which residency programs have scribes for the residents?
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Perhaps, places that use PhysAssist scribes (they have a location tab on their website). However, the website doesn't say what programs.
 
You dont' want scribes as a resident. Period.

Good charting is a skill that must be learned by you, firsthand. You need to learn how to dictate, how to use a T-sheet, and how to use EMR. The operative word here being: You.
 
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RustedFox said:
You dont' want scribes as a resident. Period.

Good charting is a skill that must be learned by you, firsthand. You need to learn how to dictate, how to use a T-sheet, and how to use EMR. The operative word here being: You.
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+1

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I'm especially ardent about this because I was a lazy, bad charter in residency.

It bit me in the ass my first month out.

I wish I didn't have to learn the hard way. That's what residency is for: sorting out what you're "good" and "bad" at, and then working on fixing the "bad".

I understand the attitude of "Hey, I just worked my ass off for four years in medical school. I don't want residency to be murder."

When you get out... it IS murder. Its you vs. the zombies. And they keep coming.
 
I agree - suck it up and put in the work as a resident. Then enjoy the perks of being an attending.
 
This has been discussed multiple times, and I think you can make an argument for and against scribes for residents...most people would probably agree that scribes for interns is not a good thing, for those very reasons mentioned above. Senior residents know how to dictate, how to use the EMR etc. and since more and more EDs employ scribes you could actually argue that residents should know how to work with them as well. But, coming back to my original question, I would be interested in knowing which programs currently have scribes for residents. Do you have scribes available 24/7? Only for senior residents? Was there a change in productivity/patients per hour? Did you department's billing improve? Any problems?
 
Senior residents know all those things... because they learned as interns and second years.

I'm not trying to get down on you, but I can't emphasize enough that one word: "YOU" need to learn how to do it; from day one and page one. I'm also not trying to be a killjoy, but I will point out the dangers of scribes. I'm a big believer that the scribe movement can be very, very good... but it is still in its infancy. Just like how the first iPads sucked... the scribe thing will suffer growing pains as well.

We tried using scribes at several of our residency program sites. I can't say it was a success because some of the scribes that we used were 1st/2nd year medical students who had no idea what they were doing in the first place, and were trying to "learn medicine as they went" instead of just "scribing". At a different site, we had "professional" scribes, who.... were no better than the students.

Having scribes should not be a residency selection criterion.
 
Resident + scribe = very bad idea..... For reasons already stated.

I've not heard one pro. A scribe is a personal assistant, if you have one when you are finished with residency.... You can figure how best to use them to increase your efficiency. That does not need learned in residency....
 
I agree with the above. If you get used to using scribes in residency and then go somewhere that does not have scribes, your will get crushed. A scribe is something you should add to your practice later to improve your lifestyle after you get out of residency. You should not be rushing that much in residency. When you are charting, it forces you to think about the case and you realize what you forgot about. It also made me read the attending's note which helped me learn how to chart. As much as a hated it, it is essential. Do not deprive yourself of learning this essesntial skill. It is also extremely important to learn contemporaneous charting. In residency, our attendings pushed us to dispo patients before the chart was done and let the charts stack up to the end of rhte shift. It think this is a really bad idea - if you learn how to do that in residency, it is hard to break the habit when you get out.
 
ptarmigan said:
In residency, our attendings pushed us to dispo patients before the chart was done and let the charts stack up to the end of rhte shift. It think this is a really bad idea - if you learn how to do that in residency, it is hard to break the habit when you get out.
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THIS is exactly how I got my ass kicked my first month out. I let them pile up. DON'T make that mistake. I got a letter from the group saying - "Hey, kid.... we like you, and you practice good, safe medicine, but we can't bill for these until you finish 'em. You're being watched. Just sayin'."


Furthermore, I understand the attitude of: "Listen, I'm here to be a good doctor... not to be a data-entry specialist. I didn't go to school for THAT." Sadly, that just doesn't fly. You saw the patient; you write the chart; you own the chart; you defend the chart.

Quite frankly, if I even HAD a scribe right now... I would simply say: "Listen. You're here to type EXACTLY what I say, how I say it, when I say it, and where I want it written. Nothing more. Its my ***** on the witness stand defending this thing, not yours. I want my chart to read EXACTLY as follows, period. There's no room for creativity or interpretation here."

Work like a doctor. Chart like a lawyer.
 
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EMIM2011 said:
This has been discussed multiple times, and I think you can make an argument for and against scribes for residents...most people would probably agree that scribes for interns is not a good thing, for those very reasons mentioned above. Senior residents know how to dictate, how to use the EMR etc. and since more and more EDs employ scribes you could actually argue that residents should know how to work with them as well. But, coming back to my original question, I would be interested in knowing which programs currently have scribes for residents. Do you have scribes available 24/7? Only for senior residents? Was there a change in productivity/patients per hour? Did you department's billing improve? Any problems?
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To directly address your question... no resident (senior, junior, or intern) is going to know how the presence of scribes affected patients per hour, or billing. That's not their job; they should be busy as hell trying to practice good medicine and improving their skill set.
 
What! Scribes for residents?? I've never heard of such a thing. Huge mistake. You need to know how to chart, document medical decision making, and eventually bill. Theres a high likelihood you'll graduate and work in a place without scribes and you'll have a hard time.
 
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University of Illinois at Peoria has scribes in the department. Interns and 2nd years can't use them. Third years can use them at the discretion of the attending (if they feel your documentation on your own is good, then you can use the scribes to see how fast you can drive the department).
 
WVU has scribes for senior residents only. They usually cover 3 of 5 daily shifts. One mid day and the overnight shift don't have scribes. Scribes also cover 1 of 2 MLP shifts in Vertical Care. We (senior residents and chiefs) have worked very hard to train them, even though they are from a national company. We are just starting to really see the benefits with improved door to doc and door to admission times, but they are paying for themselves. We use Epic (no t-sheets), worked hard to develop smart phrase templates to make scribing more uniform and easier to anticipate. The residents know all the smart phrases by heart so we can instruct the scribes to make the needed changes without re-hashing all the normal findings. Medical decision making area has prompts for specific complaints. Obviously all charts are read and tweaked by the residents before signing them. Sure makes the difference when you are seeing 2.5+ pts an hour. At 2 pts an hour using dragon and my own smart phrases is almost as fast.
 
Also it improves education opportunities. Whether you have more time to look up a study or article with an attending or sit down with a intern, medical or PA student, scribes have a value in residency. We all get plenty of time charting on our own with overnight coverage regularly over 30 pts in a 10hr shift, plus trying to watch out for the few pts the off service resident is involved with.
 
tegs15 said:
Also it improves education opportunities. Whether you have more time to look up a study or article with an attending or sit down with a intern, medical or PA student, scribes have a value in residency. We all get plenty of time charting on our own with overnight coverage regularly over 30 pts in a 10hr shift, plus trying to watch out for the few pts the off service resident is involved with.
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Are you implying that you're seeing 30 pts in a 10 hr shift regularly as their primary doctor? I'm going to call shenanigans on that. Unless your ED turns into a fast-track at night, there's no way you're doing that on average.

You're still developing your dictation style as a senior-resident (predominantly learning how to document with an increase in patient volume and acuity) and my sense is that having a scribe would interfere with that development. Things like batching charts at the end of the shift that are absolute no-nos without a scribe are actually adaptive if there is a relatively complete chart just waiting for your signature. Using scribes involves a pretty shallow learning curve, but learning how to get along without them is much more difficult. This is perhaps fresh in my mind as I just worked one of my first scribe-less shifts using electronic T-sheets in the 6 months since we switched from paper. And I realize that I had a lot of difficulty remembering the patients PMHx even when documenting immediately after the encounter since I was so used to the scribe recording it and not having to enter it into my functional memory it unless it would change my ED work-up.
 
I think efficiency is one of those things as a resident you cant really get a feel on. Not whether or not you are efficient but in the design of a residency there is tremendous ineffciency there. I believe there was an article out when I was a resident that the avg pph was like 1.4... if you are talking to someone about a job and they avg 2.2pph.. thats a huge number in comparison.

Perhaps thats the logic behind wanting scribes. I for one think its a terrible idea in academics all together. This is probably the most underestimated skills thats necessary in real EM.
 
I may have a minority opinion here but I think scribes would be great even for residents - we are training now to be information managers at an executive level. most places will adopt scribes if they haven't already and if they aren't in a academic setting - why not embrace scribe management as part of the training? maybe scribes just for the seniors so you learn charting early on?
 
Arcan57 said:
Are you implying that you're seeing 30 pts in a 10 hr shift regularly as their primary doctor? I'm going to call shenanigans on that. Unless your ED turns into a fast-track at night, there's no way you're doing that on average.

You're still developing your dictation style as a senior-resident (predominantly learning how to document with an increase in patient volume and acuity) and my sense is that having a scribe would interfere with that development. Things like batching charts at the end of the shift that are absolute no-nos without a scribe are actually adaptive if there is a relatively complete chart just waiting for your signature. Using scribes involves a pretty shallow learning curve, but learning how to get along without them is much more difficult. This is perhaps fresh in my mind as I just worked one of my first scribe-less shifts using electronic T-sheets in the 6 months since we switched from paper. And I realize that I had a lot of difficulty remembering the patients PMHx even when documenting immediately after the encounter since I was so used to the scribe recording it and not having to enter it into my functional memory it unless it would change my ED work-up.
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Regularly enough 20-30% of night shifts = 1-2 times a month, fellow resident just 2 weeks ago had 42 primary pts seen in 10hr shift. Like I say it's not every shift but often enough to remind you how to chart. Also most of us don't batch we constantly update the charts, either verbally dictating to scribe or inputting info like EKG and radiographic findings real time. My charts are almost all signed within minutes of discharge. As you say batching is a horrible habit for flow and efficiency, unless you get paid for charting.

Personally, my flow has become more tuned in I think. I've had to really employ restating as an interview technique with our rambling pts, the scribes know to use my exact words when i restate some 5 minute wandering diatribe in 3 sentences. This is just one skill that translates well scribe to scribeless pt care.

I don't argue that continuous scribe use would certainly dull or delay gaining the appropriate skill set of good EM dr, it also provides other management and flow skills.
 
We regularly see 2-3 PPH three months into our PGY 2 year, and we have EPIC, for which we must type +/- smartphrases and macros. There is simply no way to keep moving patients and complete charts during shift, not unless I clone myself. You guys must have a ridiculously efficient system if you're hitting those numbers and finishing charting during shift. If we were required to complete the chart before dispo our throughput would be dismal.
 
UnderwaterDoc said:
We regularly see 2-3 PPH three months into our PGY 2 year, and we have EPIC, for which we must type +/- smartphrases and macros. There is simply no way to keep moving patients and complete charts during shift, not unless I clone myself. You guys must have a ridiculously efficient system if you're hitting those numbers and finishing charting during shift. If we were required to complete the chart before dispo our throughput would be dismal.
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Only finishing the charts real time during higher pts per hour with scribes, personally usually when seeing more than 2.5 pts per hr without scribe help I just get the hpi dictated and some mdm info, thats when you end up batching at the end of a shift.
 
tegs15 said:
Only finishing the charts real time during higher pts per hour with scribes, personally usually when seeing more than 2.5 pts per hr without scribe help I just get the hpi dictated and some mdm info, thats when you end up batching at the end of a shift.
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Yup, same here. I stay 1-2h after shift finishing up all the MDMs. I wish we had scribes.
 
The biggest problem that I have as an attending is getting good MDM into the chart when I'm seeing 2.3+ pph in our shop. Picis (ed pulsecheck) plus scribes here.

I will say that I agree about the lack of input into functional memory vis a vis scribes. I've found that the summary statement bit ("let me see if I've understood you correctly...") goes a long way towards helping me remember them and my thought process.

Any suggestions on how to chart faster with good mdm?
 
tegs15 said:
Regularly enough 20-30% of night shifts = 1-2 times a month, fellow resident just 2 weeks ago had 42 primary pts seen in 10hr shift.
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If you are seeing 4 per hour primarily you are being robbed of an education. Your patients are too healthy, you are not doing enough procedures, and your attendings are not teaching you anything.

No one can primarily see four per hour with any kind of acuity. At that speed, you are not placing lines, doing ultrasounds, evaluating complex complaints, reducing fractures, running codes, placing chest tubes, or seeing multisystem trauma. At one of the hospitals I worked at in residency we moved pretty fast, but we consulted the psych team for suicidal patients, the trauma team for MVCs with no injuries, ortho to reduce fractures, and the stroke team to evaluate any new neuro defecit. Sure, if you have someone telling you what the disposition is on half your patients and doing all your procedures for you then you can move pretty fast. But this did not serve us well as residents, and fortunately at the other hospital we worked at things were different. Residents care too much about being fast.

If you end up practicing in the community, no one will care that you saw 4 per hour on some overnight shifts in residency. But they will care if you don't know how to reduce a fracture, if you botch a chest tube, or if you don't seem comfortable with complex patients. They will evaluate you based on how competent you appear, and seeing lots of dental pain or ankle sprains in residency will not help you with that.
 
Agreed that seeing that number of pts is really not conducive to education. I believe that he had 16-18 traumas that night, about half were probably transfers from tiny hospitals and the other half we were the initial facility.
Every residency has strengths and weaknesses, maybe you trained in a "rural" program that was unopposed, you did every procedure in the department with almost no consults but only saw 1-1.5 pts per hour vs. the "ivory tower" where consults were regularly made to 1 of 127 specialties to see pts in the ED for you, but you understand flow and disposition and can move the meat. These extremes exists on the spectrum of EM education. Knowing what you or your program is lacking and focusing on your weakness is the sign of an adult learner.
 
tegs15 said:
Agreed that seeing that number of pts is really not conducive to education. I believe that he had 16-18 traumas that night, about half were probably transfers from tiny hospitals and the other half we were the initial facility.
Every residency has strengths and weaknesses, maybe you trained in a "rural" program that was unopposed, you did every procedure in the department with almost no consults but only saw 1-1.5 pts per hour vs. the "ivory tower" where consults were regularly made to 1 of 127 specialties to see pts in the ED for you, but you understand flow and disposition and can move the meat. These extremes exists on the spectrum of EM education. Knowing what you or your program is lacking and focusing on your weakness is the sign of an adult learner.
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I think you have a good perspective there about the differences between programs. Maybe its just my perspective, but I disagree with you that in the ivory tower example the residents are learning to move the meat. In fact, they are learning how to let consultants move the meat. When a consultant sees the patient in the ED and does X procedure then rights recommendations to admit or discharge, the consultant is making the disposition. In my opinion, unless the EM residents are brought into this process as a collaboration with the consultants, they are getting screwed - robbed of their education.

And when I hear four patients per hour, I immediately know what is going on in that department. I think most people on this forum know it as well. On the 15 trauma patients, the EM resident is doing a cursory evaluation and handing it off to the trauma team who follows up on everything, including labs, scans, etc, and then admits the patient or tells teh EM resident to discharge them. The other 15 are easy dental pain and ankle sprains. 10 of those patients are actually patients that the previous resident worked up but this super resident clicked on so that when you pull it up in the computer those patietns are now creditted to said 4 pph super resident. And all the while, the senioor resident and the attending are scurrying around trying to clean up this super resident's mess.

I know this because I have seen it. Sorry, you cannot see four per hour in residency and learn anything but how to cut corners. No one in my group (most of whom trained at high volume, high acuity, extremely well respected programs) ever does 4 per hour in anything but fast track. It is just not humanly possible to FULLY evaluate, treat, reevaluate, and disposition EMREGENCY patients that quickly.
 
I think the conversation has gotten skewed. The example I gave was a senior resident working overnight with an off service residence and a single attending. If the senior resident didn't see those patients they were not going to be seen. It's not to say that it was a positive experience for him or an educational experience in anyway. It was just an example to show that scribes in residency can have their place and be productive.
The previous argument was that there is no place for scribes during residency and that if residents had scribes they would not be productive or learn how to manage a department.
 
Didn't mean to get you off subject - it's just a little agravating when a resident is saying that they are regulary seeing 3-4 patients per hour. We all know that is not possible. If we actually sat down and looked at the patients your friend worked up from start to finish, it would be much much lower.

What does it tell you that the attendings here are in the 2-2.5 range? Are you just that much faster? Something is off, or miscalculated.
 
Are scribes here to stay? Not sure. They are a great fit for our current reimbursement structure based on buzzwords, chart section criteria, and critical care documentation. But what if healthcare changed (how could that happen), and billing meant that scribes were no longer efficient or even useful?

The only reason I suggest this is that it's a good idea to have personal documentation skills to fall back on. Even as a third year resident, you should have a personal hand in every chart that you document. You are still learning. If you succumb to the laziness of the scribe in 3rd year residency, you have only experienced 2 years of training to craft your medicolegal chart. Take away intern year, which is pretty much useless for EM documentation, and you only have one practical year of documentation training.

Don't think for a minute that these residency programs got scribes to make your lives easier. They got them to increase THEIR revenue by having you see more patients for them. They do you no service except to contribute to the pervasive laziness that is infecting medicine. Emergency Medicine is the last bastion of the true hospital physician. Don't degrade your training by forgetting this key point.

I won't hire any residents who used scribes in their program.
 
As I believe I at least implied previously we "touch", update and document in every chart, especially the MDM. Of course the scribes are there to increase moving of the meat, however I believe it has actually improved press ganey score more. We were always able to see more patients and admit those that needed it then our admitting services can keep up with. Now we have a little more time to check back in on pts ourselves.
Seems like strong language to say you'll never hire a resident that used scribes, do you want to tell use where not to apply so we don't waste our time?
 
I am not alone in this thought, and several of our partners have refused to even entertain scribes as an option in our ED because of the documentation risk and medicolegal liability in our state. Yes, they help "move the meat" and may help with patient satisfaction (when used unscrupulously to elicit survey concerns in the department), but at the end of the day, they are untrained, non-clinical entities who construct the most critical evidence of your medicolegal protection. I would much rather have physicians who are skilled at constructing detailed notes on their own, clearly detail why decisions were or were not made, and also cite current literate in their documentation. Scribes do not do this, and we don't mind working harder to communicate what we need in real time to accurately reflect the care we provide and the decisions we make.

One of my colleagues referred to scribes as "crack", because once ED physicians get used to them, they cannot go back to the days without them, and that is where the quality of our work (as defined in the chart) suffers. Over time, we become dependent on scribes, and our record becomes an after thought that "someone else will do." There are benefits to having scribes for basic documentation, but the medical record is a very detailed document that varies from patient to patient. I mean no offense to those residents who do use scribes, but I urge caution to them to be mindful of what is actually being written about your care. Scribes can take a weak resident and make them weaker. They can take a very strong resident and make them more efficient, but in either case, they are no substitute for articulating the nuances of medical care.

Scribes are becoming used with more frequency nationwide, but they are further detracting from our specialty and making emergency physicians even more of a commodity than they already are. In the coming years, holding group contracts will become more difficult than ever, and as an emergency physician, you are easily replaced by the next group who delivers the fastest and cheapest care (defined as "quality" by those business-type administrators who renew your contracts). At the end of the day, even some residency programs are private groups who are feeling the same pressure as those in the community.

The groups that stay are liked by the medical staff, meet their metrics and are therefore liked by administration, and expose the hospital to the lowest liability. Residents don't think about these things much at all, and they shouldn't have to as much because they should be focused on learning how to be emergency physicians. In my mind, if a resident doesn't have the passion to learn how to protect their hard work and take complete ownership of their medical treatment at the peak of their training and when they should be cognizant of how vulnerable they are to risk, these qualities will erode even further a couple of years out of their training when they are contributing to a group.

These may be the same residents who expect to only work 100 hour months, no nights, no weekends, and earn the same salary as a full-time provider...

Strong Statement? perhaps. I'm more concerned with the longevity of our group and as I have said, I am not alone.
 
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