By Chaz Sineri
Life Before Medical School
I’ll never forget that day.
I was sitting in the ED typing a chart for a 75-year-old nursing home patient with CHF when I got that long-awaited email. It was a medical school acceptance letter! I may have whispered a few swear words before the physician asked me, “What happened? Did the potassium come back hemolyzed again?” I responded, “No, but I was accepted into Medical School!” I got a smile, a big thumbs up and a “Let’s go see the next patient in 2.” Life in the emergency room never stops.
I became a Clinical Information Manager (CIM, or medical scribe) more than four years ago. I knew before becoming a scribe that medicine was a career that I wanted to pursue, but I wasn’t sure in what capacity. I figured being front and center with all of the “hustle and bustle” of an emergency department would give me sort of an idea. Fast forward a few years and here I am at West Virginia School of Osteopathic Medicine finishing up second year and getting ready to head to Martinsburg, W. Va., to start rotations.
Transitioning from an urban city like New York to rural, country-style living was definitely a change, but I think I handled it with class. I live in “The coolest small town in America”: Lewisburg, W. Va. On the first day, I was accepted with open arms, and the whole experience has been terrific. Native West Virginians have shown me the “ins and outs” of living in a rural community and quickly became awesome—and I expect lifelong-friends. Unlike the typical medical school community, every student in the class works to help the others, and the “cut throat” competition is non-existent.
Once a Scribe, Now a Medical Student
Becoming a scribe prior to medical school has helped me in ways I could never have imagined. First and foremost, I can relate to the stories that my professors tell us. I was very lucky and grateful to work with physicians who took me to the patient’s room with them to witness the patient-physician interaction; that alone was an invaluable experience.
Being trained in writing physician charts is the obvious advantage. Having that tool under your belt heading into med school is definitely a plus. Just recently, I had the privilege of tag teaming with a fellow student to evaluate and treat a patient at a clinic. Under the supervision of a preceptor, we were responsible for obtaining a detailed history and physical. Finally, we presented the case with possible diagnoses and plans for treatment. This was a great experience, as it was something I had watched working in the emergency department day after day. As a scribe I had taken careful notes as to what was ordered (Chest X-rays, EKGs, CTs, labs) for patients with various presentations and applied that to my studies in medical school.
Within the first week of classes I found myself writing “SOAP” notes in clinical skills classes. We were taught about the “Subjective, Objective, Assessment, Plan” criteria for writing about cases. While this was a new experience for most of my fellow classmates, it was old news for me. One of our first activities was to evaluate a standardized patient and collect and write out the history of the present illness (HPI). Having the background of being a scribe allowed me to enjoy this activity while most of my classmates were as nervous as I was on the first day as a scribe.
At the hospital where I worked, scribes were scheduled in 12.5-hour blocks, spending most of the shift with the same physician. My first shift felt like it lasted a couple of days. At first, I couldn’t imagine being enclosed in an ED for that many hours, completing chart after chart. Looking back, it was great preparation for the 16-hour days that are medical school.
Occasionally, I had the privilege of observing procedures performed by the physician, such as ET intubations, ultrasound-guided central lines and full codes. During various training labs (after perfecting a specified task), I have been asked by professors, “So what did you do before coming to medical school?” I simply smile and say, “I was a medical scribe.”
What to Expect in Medical School
A typical day of medical school starts off waking up at 7 a.m. Sadly, the only “me” time is brushing my teeth, showering and throwing on some clothes. Breakfast is non-existent, any day. I’m lucky if I remember to grab a frappuccino from the fridge as I run out the door. First class is at 8:10 a.m. sharp. Depending on the body system that’s currently being studied, the topics could range from pathology to pharmacology to case studies or immunology or microbiology. Trust me: there is nothing more exciting than learning about the types of diarrhea while you are trying to wake up! As a scribe I always found it interesting how physicians would ask the patient to describe his or her stool to them. They would ask, “Is there mucous? Is there blood, is it mostly liquid? Is there any solid pieces?” Besides being grossed out to say the least, I figured there had to be a reason. Well, weeks of studying about the different mechanisms of diarrhea gives you great insight into what could be the cause, which leads you to the treatment that much more quickly. Since most people feel bashful talking about their bowel movements, I use the analogy one of my professors taught me. I simply ask, “Does it have the consistency of apple juice, apple sauce, or apple pie?” Since everyone is familiar with the consistency of these snacks, it makes the experience that much less awkward.
Each class is 50 minutes long. When a professor starts to go on and on about a case they had a decade ago and spill over into our break, you bet there are 150 pairs of eyes staring them down. That 10-minute break between classes is used to get up and get that blood flowing through those veins.
After four hours of knowledge overload, it’s LUNCHTIME. Well not really – class is at 1 p.m. and it’s Clinical Skills. That requires you to be wearing business attire, a white coat, a name tag and a smile. So lunch is spent changing. No matter how many times I go to the Clinical Education Center, I still get nervous. Well, it’s the uncertainty. You never know what’s going to be behind that door. Just like the Emergency Department!
The professor tells me, “Room Red 2.” I sit in front of the computer next to the door and wait for my doorway instructions to pop up on the screen. Finally, the scenario pops up on the screen:
A 60 year-old male with abdominal pain
Vitals: Temp 100.3, RR 18, BP 128/81, Pulse Ox: 99% RA.
Evaluate the patient…
I knock on the door, and the voice tells me, “Come in!” I quickly wash my hands and greet the patient with, “So tell me what brings you in today?” (With a gleaming smile of course).” He responds, “Ugh I’ve been up all night with this pain in my stomach.” I quickly ask him, “Can you tell me more about that?” In my head the “ding” goes off, noting to myself I got full points for my opening statements. He responds, “It started to hurt me last night here,” (he points to the lower right quadrant of his abdomen) “after I ate dinner and then I felt nauseous and vomited a few hours later.” I quickly narrow down my differential to: appendicitis, diverticulitis, a kidney stone.
I continue asking him questions: “Is there anything that makes it worse?” He tells me, “Yeah, my wife. I swear she must have hit every bump on the way here because I felt every one of them.” At this point I’m almost certain I know where this is going. I finish asking the questions and then tell him, “I’m going to do a quick physical exam.” He agrees and I begin, already having noted that he looks uncomfortable, but not terribly sick. I start with his ENT exam, and he doesn’t appear jaundiced or dehydrated. I put my hand on his shoulder and listen carefully to his heart and lungs, which seem normal—and I tell him so. I then listen for bowel sounds and begin to palpate his abdomen. When I checked for rebound tenderness in the RLQ, he nearly jumps off the table. I finish my physical exam and wrap up my encounter. The patient asks, “Doc, what do you think it is?” I respond, “Based on the history and my exam, we are going to rule out appendicitis. I am going to order a complete blood count to check for an elevated white blood cell count and a CT of the abdomen with contrast to visualize the appendix.” I wrap up the encounter and tell him to hang tight. “These tests don’t hurt, but they will take a while.” I leave the room and sit down to write up my “SOAP” note. We are given nine minutes. I imagine when I worked as a scribe in the ED and patients waiting to be seen. I quickly begin to type:
John Doe is a 60-year-old male who presents complaining of a 1-day history of moderately intense, sharp right lower quadrant pain associated with (+) nausea, (+) 1 episode of vomiting, (-) diarrhea. The pain is constant and exacerbated by movement and gets “a little better lying still.” He describes the pain a 8/10 severity. The patient has no appetite and has not eaten since the evening when he vomited. The patient has had several brown stools that are not blood streaked nor tarry in nature. He denies any recent travel, consumption of uncooked or undercooked foods. He reports feeling “a little feverish”, with (+) chills. He reports (-) dysuria, (-) increased frequency, (-) contact with others with similar symptoms. He denies ever having a similar episode in the past. His medical and surgical histories are unremarkable. He does not smoke, drink or use illicit drugs. He does not take prescription medications, over-the-counter medications, or herbal supplements. The patient is not allergic to any medications, has never been hospitalized and is up to date on all immunizations. He is a married man in a monogamous relationship, who feels safe at home. He works as a paralegal, is a born-again Christian, living in the rural hills of West Virginia.
I continue to type my physical exam, assessment and plan. Done with a minute to spare! I give myself a pat on the back as I walk out of the door. So, I’m free for the rest of the day, right? WRONG! The day has just begun. Remember those classes from this morning? There are 100 pages of reading to go with that material that needs to be sifted through before tomorrow’s classes. Since medicine is constantly building upon concepts, it’s important to understand the core concepts, or figuring out subsequent information will be a challenge. So off to the library I go to find a corner to nestle myself into and study until I find my forehead on the keyboard.
The Scribe Advantage
There is no doubt that becoming a scribe prior to medical school has had its benefits. The most obvious advantage is being able to answer the question: Is medicine a career I want to pursue? Observing the daily routine of an emergency department as well as typing physicians’ notes, coding etc., gives you unique insight into the joy, stress and fatigue of practicing emergency medicine. The scribe training class taught me the art of typing physicians’ notes, diligently gathering and disseminating diagnostic exams and coding for all of the procedures performed — all invaluable skills that will be used every day in the medical field. My recent medical school class on coding was a “no brainer” after coding thousands of charts as a scribe. Since I had already learned about “Evaluation and Management” (E&M) codes and procedure codes, I was able to easily follow along.
But most important, as a scribe I gained great respect for the physicians and associate practitioners I had the privilege of working with. When a physician asks you to complete a task, you do it to the best of your ability with a smile. And once the physician knows you are a medical student, you can expect to be grilled on the minute details from all of those late nights studying!
Charles Sineri was a Clinical Information Manager for Emergency Medical Associates at Richmond University Medical Center, Staten Island, N.Y. Sineri received his undergraduate degree from Drexel University, Philadelphia, and is a second-year medical student at West Virginia School of Osteopathic Medicine, Lewisburg, W.Va. He plans to pursue a residency in emergency medicine and practice in New York City.