Medical School Perspective Through the Eyes of a Scribe

By Chaz Sineri    Sineri Charles

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.

New Beginnings

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.

From Road Warrior to King of the Castle

By Dr. Schubert Perotte      Perotte

6.5 years out of med school, I had the opportunity to join an emergency medicine staffing support team, a group of “nomadic” physicians who are dispatched to the sites that have temporary staffing holes.

For a fairly new physician, this experience enabled me to get a taste of different practice settings, travel and live a bit more spontaneously. Now, several years later and more settled both personally and professionally, I relish the normalcy of my routine. My advice to EM physicians exploring their options is to take advantage of opportunities like a staffing support team to see what’s out there.

2010: Kingston, NY:

It’s 6 a.m., and I’m in a hotel. The alarm on my cell phone goes off, the sound blasting me out of sleep. I wake up and walk into the brightly lit and perfectly clean bathroom with everything in its place, including fresh towels and a new unopened packet of soap.

After showering brushing my teeth, and getting into my scrubs, by 6:40 a.m., I’m walking out the door, headed to a local eatery for my breakfast routine of two fruit and maple oatmeal cups and a phone call to my wife.

At 6:55 a.m., I pull into the parking lot of HealthAlliance of the Hudson Valley’s Kingston Hospital to start my day as an EMA Staffing Support Team (SST) physician.

At the end of my shift, I either call ahead to place an order at a local restaurant or stop by one of my favorites to try the special of the day. Having great restaurants in the area you work is great for eating – but terrible for dieting. Back at the hotel, I check my email, call my wife and family, then hit the gym or watch a movie.

On days off in the fall, after the leaves begin to change, I take time to enjoy picking apples and sampling the local beer and wine. I look forward to winter, when I’ll get time to ski in the Catskills.

2011: Lumberton, NC:

Southeastern Regional Medical Center (SRMC) in Lumberton, N.C., is a different experience from Kingston – mainly because the emergency department is larger. There is a true sense of southern hospitality. The people are nice, and the physicians and work experience is top notch. Patients are initially seen by a primary care physician, physician assistant or triage nurse, so by the time I examine  them, most of the lab work is done. It’s an extremely efficient process.

The overall experience — the people, food and great weather – is what makes SRMC so attractive. The doctors are an inviting group. In fact, the staff physicians often take me out to lunch or dinner, so while I may be away from home, I never feel lonely.

The doctors at Lumberton try to convince me to make the move to North Carolina, but I plan to stay in New Jersey. But I know when I visit North Carolina in the future, I’ll have a place to stay with the friends that I’ve made.

2013: Back home in New Jersey:

It’s 6 a.m., and my wife and I wake to the blaring sound of the alarm clock.  We both get out of the bed; she heads to the kitchen, I head to the shower. I brush my teeth and check out her section of the bathroom counter – her brushes, make-up bag and hair care products are all in their accustomed place within easy reach. Very different from my own motel room neatness…but it’s great to be home.

As I finish my shower she pops in to say goodbye before heading to the gym. I go to my closet, pick out a shirt tie and coordinating pants. Dressed and ready, I go to the kitchen and find breakfast prepared and lunch neatly packed in my lunch bag – a turkey sandwich, carrots with dip, an apple and a pear. I eat my breakfast and head out the door at 6:50.  Yep, it’s great to be home.

At 7:25, I arrive in the parking lot of the Bayshore Community Hospital in Holmdel, ready to start my shift.

If the shift is over early enough, I give my wife a call to see if she needs me to pick up anything from the supermarket. When she arrives home, she starts dinner, with me as enthusiastic first assistant. At about 7 we sit down, have one of our favorite home-cooked meals, and discuss the events —always ending with whatever was the best part–of our day.

Some Things Never Change

When I think about what it is like to work as a traveling physician as opposed to having a home base– aside from my morning and evening routines and the inevitable hospital idiosyncrasies there aren’t many differences.  The day-to-day aspects of patient care are universal. There are the usual calls to Radiology and the Lab as private physicians try to expedite their patients’ admission or discharge.  Through it all, I try to balance great patient care, documentation, efficiency, a bite to eat — and on a  lucky day, a bathroom break. At all sites there are associate practitioners, scribes, nurses, medical technicians and unit clerks who make the job of caring for the sick, injured and scared run more smoothly. Working so closely together, we easily develop a sense a family.

Combining Cultures

One experience unique to working on the Staffing Support Team is the ability to establish our company’s culture within a new site. Each new contract brings with it the opportunity to build relationships that allow both the staff and hospital to grow. I have always felt welcomed by each new site because the administration and staff understand that we are there to deliver the highest-quality patient care and do what is right during each patient encounter to support the team. And while Emergency Medical Associates has its own policies and procedures, we always work with our hospitals to create a team that meets everyone’s expectations.

At the End of the Day

The biggest benefit of being a member of the SST was the exposure to different ways to deliver emergency medicine, depending on the community. The Staffing Support Team exposes you to different hospital cultures and makes you a more well-rounded physician.

Being an emergency medicine “road warrior” offered many benefits and opportunities that were attractive to me earlier in my career. I had the flexibility of traveling to hospitals and gaining front-line experience. But now I know how important it is to spend more time at home with my wife and assume our roles as “king and queen of the castle.”

Schubert Perotte, MD, FACEP, is an attending emergency physician at Somerset Medical Center in Somerville, N.J and Bayshore Community Hospital, Holmdel, N.J. Dr. Perotte is a partner of Emergency Medical Associates. He is a recognized researcher and lecturer in the field of evidence-based medicine. Dr. Perotte received his undergraduate degree from Rutgers University, his medical degree from Robert Wood Johnson Medical School and completed his emergency medicine residency at Newark Beth Israel Medical Center.

Communication is the Best Medicine

By Marc Milano, MD, FACEP Caring doctor with ill patient

As ER doctors and mid-levels, we live in the emergency room. It is our home away from home. And each room can present a new and exciting challenge.  But for a patient, each room can present a new and frightening uncertainty: Will this hurt? Am I having a heart attack? Am I going to die? As clinicians – and caregivers – it is our job to help ease the worries of our patients. Our tone of voice, our facial expression, every part of our presence in the examination room will have an effect–positive or negative– on the patient’s experience.  If that effect is positive, it can lead to better patient outcomes, decreased medico-legal risks—and a better shift for you. And if you keep stringing better shifts together, sooner or later it adds up to a better career.

Don’t keep secrets from your patients

Let patients know, within reason, what you are thinking at every point in the encounter. It is a real privilege to give this insight and it will be appreciated. For example, express your findings while examining the patient. “Your lungs are nice and clear” or “you seem a little tender right here,” engages and reassures patients and lets them know both that you are paying attention to the exam and that you are making an effort to communicate with them. Telling patients what you think the problem may be or your preliminary diagnosis BEFORE ordering tests might even avoid some tests if the patient has been given a good rationale and you have earned his or her trust. You may well be able to confidently reassure them that the problem they were most concerned about–or even terrified of—is in fact not present. You will have a very relieved and very grateful patient.

Honesty is the best policy

We hold ourselves to extremely high professional standards and expect even more of ourselves than our patients do. At times, however, we may encounter a difficult or uncommon problem that we haven’t previously encountered. It is best to be honest with patients if you are uncertain about their diagnoses. A good example of this is with rashes – often tricky to definitively diagnose in the emergency department. It is best to explain the possibilities, discuss treatment options, and give appropriate referral advice. Patients appreciate honesty. And even if we can’t identify the rash, we may be able to make the critical determination: “I’m not entirely certain what this represents, but I’m confident it’s not the rash of …” [shingles/Lyme disease/smallpox/Ebola/etc.]

The emergency department is our second home, so it is best to treat our patients like guests. Worried guests.

Marc A. Milano, MD, FACEP, is an emergency physician at Somerset Medical Center in Somerville, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. He is the medical director of emergency medical services (EMS) at Somerset Medical Center. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

**Catch Dr. Marc Milano on WMTR 1250 AM on Sunday, March 24 at 9:30. He will be a guest on the “Answers Live” call-in radio show**

Jersey City Medical Center Emergency Department Staff Returns ‘Home’ After Being Displaced by Hurricane Sandy

By Jodi McCaffreysuperstorm

On Dec. 22, nearly two months after Hurricane Sandy hit the area and forced the temporary relocation of the emergency department at Jersey City Medical Center, the staff has finally returned to its renovated emergency department.

During the late October “superstorm,” four feet of water surrounded the hospital. Despite sandbags and other precautions, nearly two feet of water breached the building and flooded the entire first floor – including the ED.

Dr. David Castillo was resuscitating and intubating a patient as water rose above his shoes. It was only after the patient was stabilized that he could be safely evacuated to higher ground. Another patient actually swam to the ED in hopes of finding a warm, dry place to ride out the storm.

“We thought we had planned for the worst, but it was so much more complicated,” said Michael Bessette, MD, medical director of the emergency department. “We had experienced flooding with Hurricane Irene, but nothing like this.”

Dr. Bessette and Cheng-Teng “Bill” Wang, MD, re-arranged the schedule to enable staff to arrive before the storm was due to strike– and to stay overnight if needed.

As the water rose in the ED, patients were transported to the PACU on the second floor, since elective surgeries had been cancelled in anticipation of the hurricane. The displaced ED team was already facing higher-than-normal patient volumes when a fire in Jersey City brought 30 to 40 firemen to the ED. Recognizing the crisis, the National Guard set up a makeshift shelter and medical clinic at the Jersey City Armory, so ultimately some of the less severe cases were referred there.

“Patients didn’t want to leave,” Dr. Bessette explained. “At home, they had no heat, no electricity. Schools were closed, most pharmacies were closed, doctors’ offices were closed. Patients who needed oxygen couldn’t get it. Transportation systems were down, so even those with a safe place to go couldn’t get home. And our patients have a lot of social issues, so we had to improvise to get them in touch with the community agencies that could provide the services required.”

Cell phone and email systems were affected by the storm, further hampering communication and coordination. Medical center staff connected with the few pharmacies that remained open to expedite getting patients the medications, nebulizers, methadone dressings and other supplies they needed.

After the flood waters receded, the ED was declared unusable. Six ambulances were lost due to the flooding and 60 employee cars were totaled. The whole department had to be reconstructed section by section. A seven-bed trailer was parked outside and used as a fast track area to keep patients moving through the system during repairs. No equipment was lost in the flood, according to Dr. Bessette, so what could be moved was transported to the appropriate area.

“The staff adapted well,” said Dr. Bessette. “It was difficult having our department spread out in different locations both inside and outside the medical center, but the staff did a great job.”

As can be expected, the ED’s wait times and LWOB rate suffered during the disruption, but Dr. Bessette reports that because of the diligence and resourcefulness of the staff under very difficult and stressful conditions, the quality of care was not affected.

Jodi McCaffrey is the Director of New Business Development Marketing for Emergency Medical Associates. Ms. McCaffrey joined the company in 2010, bringing 15 years of healthcare public relations, communications and marketing experience. Previous roles include serving as manager of publications and web development for Somerset Medical Center, Somerville, N.J., and editor at Health Resources Publishing, Manasquan, N.J., publisher of more than 25 industry-related monthly newsletters. She has extensive experience in web content creation, social media strategy, publication development, public relations and internal and external communications.

Ms. McCaffrey holds a master’s degree in corporate and public communication from Seton Hall University, South Orange, N.J., and a bachelor’s degree in English/creative writing from Montclair State University, Upper Montclair, N.J. She is a member of the American College of Healthcare Executives, Public Relations Society of America and Healthcare Marketing and Planning Society of New Jersey.

Big Data in a Big World

big data (2)By Eric Bachenheimer, MBA, MHSA, FACHE

As we approach the end of 2012, news headlines have us focused on many things: the impact of the U.S. presidential election, political unrest in numerous countries, development of new governments and a man free-falling to earth from space. In the midst of all this, you may not have noticed that we have entered into the age of Big Data.

Big Data is the concept that there is now so much data available that it creates difficulty in processing and analyzing it. One would think that having more data would be better for performing advanced analyses to obtain deeper meaning from vast terabytes of data in “the cloud” to support better decision-making and learning. More is better, right?

While this is true to some degree, there are challenges with just how much data is being captured now, and healthcare and emergency departments are no exception. Consider that the federal incentives for doctors’ offices and hospitals to establish electronic record systems persuaded many to finally migrate over from the ancient pen and paper methodology. The Meaningful Use certification has further stimulated software vendors to provide ever more robust data capture, and hospitals and physicians alike have already begun to embrace this. All the while, the back room computers and servers continue to process and store more and more data points.

So now what? Well, we need to find a way to navigate Big Data.

The Centers for Medicare and Medicaid Services (CMS) have developed an extensive series of quality measures applicable to hospitals, and its data reporting requirements have continued to grow correspondingly larger in scope and depth. The Emergency Department data set that was introduced last year contains a variety of measures, such as median arrival to provider time, median arrival to departure time, median decision to admit to departure time, and walkout percentages. And other measures are slated to be released in upcoming years.

While CMS is in a “collection phase” right now, the next step will be to provide analysis of the measures from U.S. hospitals to identify benchmark performance levels. These will help hospitals analyze how they stack up against competitors, as well as how to identify opportunities to improve upon these measures. But CMS won’t be stopping there. In the next two years, we can expect to see incentives and penalties attached to hospitals’ Medicare payments based on performance levels on these measures. The goal is to create an incentive for hospitals and providers to improve performance and further enhance both efficiency and the quality of care. Big Data is only getting bigger. And, CMS, by defining key healthcare metrics, will provide important guidance for hospitals and providers on areas to focus on to make Big Data more manageable.

 Eric Bachenheimer, MBA, MHSA, FACHE joined Emergency Medical Associates in 2004 and is the Director of Client Solutions for the ED Solutions team which advises and assists clients with achieving operational efficiencies, process redesign, enhancing patient satisfaction, and ensuring regulatory compliance. He has more than 10 years of experience in the emergency department industry.  He holds a master’s degree in health services administration from the University of Michigan, a master’s degree in business administration from New York University, and a bachelor’s degree from the University of Massachusetts at Amherst. He is a certified emergency medical technician and has worked in EMS for nearly 15 years. He is a Fellow in the American College of Healthcare Executives, and serves on the editorial advisory board of ED Overcrowding Solutions. Bachenheimer also is an active member of the American Association of Healthcare Consultants and the Healthcare Financial Management Association.

Sands Through the Hourglass: Tips for Maximizing Your Time With Each Patient

By Marc A. Milano, MD, FACEP

Marc Milano, MDTime. Some would say it is the most precious commodity. It can’t be bought, sold or owned. Once it is lost we can never get it back. Nowhere is this truer than in the Emergency Department. It is an understatement to say that time is rather short in the ED and that success or failure can depend on our efficient use of time. Face time with providers is what patients value most, and by employing some simple strategies you can spend remarkably little time with your patients and still have the desired effect. Here are two tips on how to use the time you have with your patients to maximize the impact and create an environment that patients will appreciate.

Time is Just an Illusion‏

The question “Doctor took time to listen” on patient satisfaction surveys is often a challenge. Studies show that the average time to first interruption by the clinician during the patient’s account of the history of present illness (HPI) is 17 seconds! This creates the perception that you are rushing them. Other literature has shown that allowing patients to finish their stories before asking questions or redirecting them ultimately takes less time than interrupting and prompting patients for more information.

To maximize the subjective time you spend with patients, use techniques like sitting on the bed or at the bedside, leaning in during conversation, keeping eye contact—if it’s culturally appropriate–, and repeating/summarizing the facts back to the patient to show that you are LISTENING and care about what they have to say. Patients will feel you spent much more time with them than you actually did.

The Pit Stop

When seeing new patients, especially given the geography of a large ED, try to quickly stop by and catch up with “old” patients in the same area. Simple, focused questions like, “How is your pain?” will keep the interaction brief. This saves time and can really score big in terms of patient satisfaction. It gives patients the sense that you are on top of things. And even more important, it  gives you a chance to discover any issues or problems, to begin service recovery steps if necessary, and to convey to patients the fact that you care about them.   Try these simple, effective methods on your next clinical shift. You’ll see that you can bend the perception of time — and you’ll see patient satisfaction scores climb!

Marc A. Milano, MD, FACEP, is an emergency physician at Somerset Medical Center in Somerville, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. He is the medical director of emergency medical services (EMS) at Somerset Medical Center. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

Behind the Curtain: A Day in the Life of an ED Scribe

By Franklin Pachay, Jr.

Keyboard“Clinical Information Manager,” or simply “CIM,” is my reply when a new face in the emergency department (ED) asks what I do. The reaction that follows is probably best described as awkward confusion. I make sure to follow through by explaining that I’m a medical scribe and outline a few things that I do: I help create the physician note; I get the radiology results into the charts; I follow up with labs; I increase clinician productivity. The person who is asking usually exclaims, “Oh! You type the charts!” I smile, nod and leave it at that. The reality is, there is much more to it than just “typing charts.”

My background aligns with most other medical scribes. I studied science as an undergrad and have always been fascinated by medicine. Many of my fellow scribes got into the job as a way to work side-by-side with doctors and midlevel providers (PAs and NPs) with the goal of obtaining experience before their move up to the next rung of the professional ladder. The exposure to what medicine “is really like” becomes invaluable. It’s definitely not Grey’s Anatomy, House or whatever your favorite medical TV show may be.

Generally, there are three ways to work as an ED scribe:

  • Time permitting, you can follow the physician into the room and take notes during the physician-patient encounter. Patients’ medical histories can be very complex. They can easily start talking about one thing and hop into a seemingly unrelated complaint. You have to talk over the case with the physician to make sure you’re both on the same page – especially to assemble the bits and pieces to complete a history of present illness. You’re then able to see how physical exams are done. With time, you’ll witness the proper way to do abdominal exams, neurological exams, chest and respiratory exams, full trauma exams, etc. It’s a great way to learn.
  • The second way is to take dictations from the provider several patients at a time. This is probably the most efficient way when there are a lot of patients and you’re working with multiple providers. For example, I work with two attending physicians and a midlevel provider in the ED. The work builds up quickly and it tests your organizational and listening skills and ability to work under pressure.
  • The third way is a mix of the previous methods. I’ll take dictations and work on the notes, but make myself available to see the more complicated or time-consuming cases with the provider. For example, trauma alert activations and cardiac arrest are cases where an immense amount of information is flowing and you have to record all of the findings, medications and history to produce a chart that accurately documents what happened during the patient’s ED visit.

I start my shift by peeking into the waiting room during my walk into the ED. Usually there are a handful of people in the waiting room at 7 a.m. Other times, I’ll only hear the morning news blaring from the waiting room TV, with not a soul in sight. The emergency department can be eerily quiet as you walk in. You’ll see the clean, ready stretchers lined up in the rooms. The tired, battle-worn overnight staff is giving turnover reports to the morning staff while adding in water cooler small talk: the weather, gossip, new toys at home, the kids, the spouse, recent vacations, etc.

I get to my location, seated next to the ED physicians and midlevels, and greet them. My next step is to look at the patient tracking board. Two patients are waiting for CT studies, one pending an ICU consult, two are waiting for surgical consults, another pending sobriety prior to discharge, six admissions are waiting for inpatient beds, and the waiting room has about four cases of varying acuity. Not a terrible way to start the day.

Not long after the beginning of my shift, one of the doctors will dictate a few notes. With paper and pen at the ready, I get set.

“John Doe in room 8 is a 47-year-old male complaining of non-radiating epigastric pain and nausea since 3 a.m. He does have a history of gastritis and reports having consumed spicy foods and beer last night. He took Maalox with no significant improvement. Otherwise, no chest pain, vomiting, diarrhea, fever, dyspnea, GI bleeding, urinary complaints. His review of systems is unremarkable except for recent exacerbation of his chronic lower back pain, which is not bothering him now. Patient has history of hypertension and had a cholecystectomy 5 years ago. He smokes 1 pack per day and is a social drinker; no drugs. His father died of an MI at age 74. Medications: Maalox and Metoprolol. No allergies. Patient is awake, alert, and in mild distress. Vitals are in the nursing note and are normal. Exam is normal except for mild epigastric tenderness without guarding or rebound, and bowel sounds are present. Normal heart sounds, clear lungs, good distal pulses. His EKG is sinus rhythm at 78 beats per minute with no acute changes. I can’t find an old EKG to compare. We’re going to give him some GI medications, observe him in ED, and do some blood work including cardiac labs. I’m not sure if we’re keeping this guy yet; I’ll re-evaluate him after his meds and we see his labs.”

That sounds fair enough, right? Have someone read that out loud to you while you scribble the notes in less than 30 seconds or so. Not impossible, but you have know the language and pay attention to the details.

“Jane Doe is an 8-year-old girl whose mother states that she twisted her left ankle while running around with friends yesterday afternoon. Patient has been able to walk, but with pain. Mom gave her Motrin with temporary relief. She does have a history of prior left ankle sprain two years ago. No other injury. No other medical history, medications, or allergies. Exam showed a smiling little girl who’s interactive with mother and me. She does have some mild anterior lateral left ankle tenderness with no deformity or swelling. She has full range of motion of ankle and foot but with pain. Good DP and PT pulses. She is able to move all toes. Her X-ray was already done, showing no fracture or dislocation. I’m going to place an Ace wrap, and the nurse will instruct patient in crutch walking. Mom instructed to continue giving Motrin for pain as needed. They will follow up with their pediatrician in 2 to 3 days.”

I love these! They are to the point and not overly complicated.

Sometimes I get dictations with three or four unrelated complaints with various time frames and complicated outpatient workups. The exams are very detailed and I have to follow up on labs, X-rays, CT scans, EKGs and urine analyses, and document re-evaluations of the patient. Then I have to document the consults and conversations with the patient’s primary doctor and cardiologist. The patient “cannot afford his medications,” so social services get involved, adding to the documentation. Then, the patient’s condition worsens to critical.

Something happens, such as the patient developing very low or high blood pressure, a fast or slow heart rate, a change in mental status, a seizure, or difficulty breathing. The doctor re-evaluates the patient, orders more medications with IV drips; more labs are drawn, and the consults are contacted again. The primary physician is contacted again and agrees with ICU admission. I keep track of all of this information in an organized matter. It can take a long time to document all of the changes, discussions, results and dispositions. Sometimes I wish I had more ankle sprains to write about, but what is the fun of that?

I repeat this process multiple times during the shift between the providers I’m working with. I write about abdominal pain, chest pain, shortness of breath, lacerations, head injuries, psychiatric emergencies, pregnant patients who are bleeding, leg pain, strokes, and I can always count on someone coming in with a cold to request a note for work. Some days it seems like there must be complimentary shuttle buses to the ED as patients come in droves!

Focus is an important aspect of the job. I’m trying to get EKGs and radiology reports, and make sure I’ve written all the notes being dictated. I work through background noise as I try to pay attention to dictations when there are four other conversations within a 10-foot radius. Then the nurse asks me to give the doctor a message. My hearing, sight and even smell are all activated in this sort of total information absorption. I’m managing clinical information in a high-paced environment to compose a detailed, accurate, medical record that will reflect the whole visit for others who care for the patient as well as his insurance company and—sometimes it comes to this—his lawyer. No mistake is too small to be important.

The job certainly has its rewards. I’m exposed to so much knowledge, and everyone wants to teach if asked appropriately. The providers explain what to look for in chest X-rays and EKGs. It gets to the point where you almost know exactly what they are going to order for specific complaints. And you learn to respect the confidentiality and privacy of every patient. You never look at charts that aren’t yours, discuss patients except with their doctors, or put any information on your Facebook page.

I’ve been able to watch our providers perform a variety of procedures, such as endotracheal intubations, spinal punctures, laceration repairs, incision and drainages, dislocation reductions, chest tubes, transcutaneous pacing and central lines. I’ve seen nurses start IV lines in mere seconds and have wondered if they can do it with their eyes closed! I’ve seen teamwork and organized chaos as someone is rolled into the ED by EMS after cardiac arrest. I’ve seen lives being saved.

No, it’s not TV. It’s better.

Franklin Pachay Jr. earned a bachelor’s degree in biology from Ramapo College of New Jersey. He has worked as a medical scribe for Emergency Medical Associates since 2008. He is based primarily out of Jersey City Medical Center, however, he also has worked at Christ Hospital, Clara Maass Medical Center, Meadowlands Hospital and Medical Center, Benedictine Hospital and Roger Williams Medical Center. When he is not in the emergency department, he also works as an EMT and EMS supervisor for the Borough of Paramus, N.J.

Time Out: Take Time to Strengthen Your Team

By Shilpa Amin Shah, MD

ACEP Image

Meet Dr. Amin Shah and other contributors to this blog at Booth 1801 at the 2012 ACEP Scientific Assembly in Denver!

I recently attended the annual Advanced Emergency and Acute Care Medicine Conference in Atlantic City. While I found all of the lectures to be informative, the one that left the biggest impression on me was about teamwork.

As an emergency physician practicing in multiple EDs, I find that my team is intricately involved in helping me make life-saving decisions quickly. That team is comprised of many members – associate practitioners, nurses, techs, unit clerks and a scribe, and I count on them during every shift that I work. The dynamics of the team dictate how smoothly the shift goes.

The lecture, entitled “Building High-Performance Teams,” drew on the experiences of three very different healthcare professionals – a practicing emergency physician, a chief financial officer from an ED outsourcing company, and the president of a healthcare professional services outsourcing company. The panel provided a few pointers for constructing more successful teams.

Here are the tips they presented, plus a few of the pearls I’ve learned in my career thus far:

  • Communication: This is the most important task for the team leader. You should communicate your plan for the patient to the nurse and tech as soon as you have one. For example, after examining a patient, I will often find the nurse and tell him or her what lab and radiographic tests I’m ordering. This way if there is a delay, the nurse is on board with the plan and can help expedite the results. And, of course, be sure to communicate your plan to the patient and family and give them a realistically estimated time that the results will be back.
  • Be Approachable: Your team members should feel comfortable coming to you with their questions. Bring a positive attitude to work. This sets the tone for the entire department and allows you to be more productive—spending more time practicing and less time dealing with disgruntled patients, families… and team members.
  • Empower People: Know your team members and empower them to order tests as they see fit.  This involves trusting your associate practitioners and nurses and relinquishing a bit of control, but empowering the staff can significantly expedite turnaround times on very busy days.
  • Recognize Individual Strengths: Each member of the team brings specific skills that make the entire team more productive. For example, if you know that Nurse A is really good at placing IVs and your patient in bed 11 is a hard stick, ask the nurse for help.
  • Team Huddle: Run through the list of patients with the physician assistant or nurse practitioner to find out if there are any particularly challenging cases. I try to “run the list” at least 2 or 3 times a shift.
  • Say “Thank You.” After your shift is over, thank all of the members involved. Everyone loves appreciation for their hard work.

Shilpa Amin-Shah, MD, is a full-time attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and two young children.

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Meet Dr. Amin Shah and other contributors to this blog at Booth 1801 at the 2012 American College of Emergency Physicians (ACEP) Scientific Assembly in Denver!

The Wisdom of 100% Pre-Admission Review for Medical Necessity

By John Fontanetta, MD, FACEP, and William Indruk, MD, FACEP

image of electronic medical recordGiven the rising cost of providing patient care and increased scrutiny by compliance organizations to find and correct improper payments, hospitals should be establishing a standard so that all patients are screened prior to admission to determine the appropriate care setting.

Industry wide, the hospital admission screening process is a bit of a misnomer. The vast majority of reviews are conducted after admission. Today, hospitals attempt to conduct their reviews within 24 hours of admission. However, the process often can extend beyond 24 hours, and sometimes the admission review is completed only after a patient has actually been discharged. This leads to incorrect admission decisions and denials, and because of the process delay, produces little opportunity to affect the initial placement of the patient in the appropriate setting, therefore adversely affecting hospital reimbursement.

Because even an occasional admission mistake can cost a hospital thousands of dollars and risk compliance errors, the obvious solution is to conduct admission screening by trained healthcare professionals in real time. However, most hospitals do not have the patient volume to justify staffing a position that would allow 24/7 coverage.

Expecting the ED physicians to be able to effectively screen patients for admission is fraught with problems. Admission criteria are a moving target and sometimes do not correlate well with clinical considerations. Gaining ED physician compliance can be time consuming and difficult; there may be a high turnover, there is sometimes misalignment of the hospital’s goals and those of the ED physician. The hospital wants to get this decision right every time whereas the ED physician may err on the side of admission to expedite flow through the ED and address liability risks. But doing so without a comprehensive admission assessment may lead to a retrospective denial of the admission, costing the hospital an average of $3,000 to $6,000–a significant risk exposure.

Hospitals now have the option of using a third party service to provide evidence-based best practices in a way that guarantees that a trained expert, utilizing an automated application, is making the decision every time. It is important that the process be applied in a consistent way, ensuring up-to-date, evidence-based criteria such as Milliman or InterQual are applied to the admission review process.

Jersey City Medical Center (JCMC) – Case Study
JCMC, a busy inner city, Level II trauma center, treats more than 80,000 patients annually. In May 2010 the hospital piloted an admission screening program. Like many hospitals, the variability in patient volume, coupled with the difficulty in recruiting experienced case managers, made it difficult to provide 24/7 ED coverage. The ED had a dedicated case manager providing weekday coverage for only one shift and with only limited weekend coverage. With the changing landscape of regulatory compliance for federal, state and commercial payers, JCMC recognized the need to conduct admission review in the ED.

JCMC selected a third-party admission review company that provided real-time admission review services to determine medical necessity and the most appropriate care setting. The innovative model utilized experienced reviewers trained on the most up-to-date InterQual Criteria® or Milliman Care Guidelines®. The emergency department’s medical records of patients being considered for admission or observation were submitted electronically for review to determine the following: meeting inpatient admission criteria to a medical floor, telemetry or ICU, outpatient observation status, or neither. The service was available 24 hours, so patient charts were referred to an admission review service center when the hospital’s case managers were off duty or unable to screen all potential admissions due to surges in ED patient volumes.

The pilot program produced positive results for JCMC in all areas of admission review. Within the first four months, JCMC achieved a 9% decrease in patients slated for admission who Did Not Meet Criteria for Admission and an 11% increase in cases who were initially slated for observation but who actually did Meet Criteria for Inpatient Admission.

The Audit Trap
With the rollout of the Recovery Audit Contractor (RAC) program, hospitals now have to be increasingly concerned about the admission process. An effective real-time admission screening process allows physicians to focus on treating patients and case managers to focus on their many other patient care responsibilities. Lastly, utilizing a company to conduct real-time admission review leads to enhanced compliance through the consistent application of the most up-to-date medical necessity criteria.

Potential Questions
There is always a potential concern that the focus of admission screening is financial. And indeed, an automated process provides a feedback loop that outlines the documentation required to meet the admission criteria. This could be perceived as feeding the physician the data to substantiate an inappropriate admission. However, the reality is that this type of feedback highlights details that the physician may have failed to provide, or may provide reassurance to the physician that admission is not necessary, ultimately improving patient care and quality. Also, admission criteria are becoming more clinically oriented and evidence-based, helping improve quality while assisting in admission decisions. Implementing the process can save the hospital time and money, but the focus is on determining the most appropriate care setting for each patient by consistently applying the latest in medical understanding and best practices with review from an objective third party.

The 100% Admission Compliance Future
The future is clear; each case must be reviewed prior to admission against current evidence-based criteria, and each case must be sufficiently documented to support the care placement decision. For every admission review, the intent to follow guidelines needs to be clearly established, and documentation made available for audits, disputes, education and any other reporting needs. Most importantly, patients must receive the care they need in the most appropriate setting – enhancing the overall safety and quality of patient care.

John Fontanetta, MD, FACEP, is chairman of emergency medicine at Clara Maass Medical Center and chief medical officer for Proven Healthcare Solutions.

William Indruk, MD, FACEP, is chief compliance officer for Proven Healthcare Solutions.

Return to Proven Healthcare Solutions Website

The Curse of the Empty ED Waiting Room

By Phillip M. Stephens, DHSc, PA-C

Photo of Phillip StephensWe measure things in medicine and pretend the numbers have meaning. One problem is a lack of measurement sophistication. Another is a lack of basic understanding of biological modeling. Let’s apply this hypothetically.

Walking through the Fast Track area of the Emergency Department one day, we see a nursing assistant pick up six charts in order to retrieve the six Fast Track patients waiting in the lobby. A nurse reminds her that Dr. Discrete Time (his name reflecting his modeling worldview) is working. Without further discussion, the nursing assistant puts half the charts back, retrieving only three patients from the lobby instead of six.

Asked what just happened, the nurse explains that Dr. Discrete Time typically accuses Fast Track of not working hard enough if he sees the lobby empty or very few patients in Fast Track rooms. He will complain or pull their staff to help him in other parts of the department if he momentarily sees this on the computer screen, slowing their flow even further. She explains that when he works, they have to work slower so he will think they are working faster.

But she goes on to explain that when Dr. Continuous Time (again named, cleverly, for his modeling methodology) is working, they do the opposite. They try to empty the lobby and turn the rooms over as fast as possible because Dr. Continuous Time thinks Fast Track is not doing their job unless the opposite occurs. He views flow being optimal if they can keep the lobby and rooms empty – the opposite perception of Dr. Discrete Time.

As a result, she says, when Dr. Continuous Time is on duty, they work faster. He never pulls staff and sometimes sends help if they get backed up, which they try not to let happen as things seem to run smoother when Dr. Continuous Time works.

She then provides more than anecdotal evidence by producing a patient list of a day when Dr. Continuous Time was working. The lobby and rooms stayed empty all day, yet they saw 30% more patients than when Dr. Discrete Time worked with the same daily volume.

Two separate processes are occurring in this scenario. A dichotomy between modeling and human behavioral economics is at work. Both must be considered. Discrete time modeling, as you have guessed, examines snapshots of time. Continuous time modeling examines a broader swath of experience. Discrete time modeling is a photo while Continuous time modeling is a video.

But neither is perfect. Neither accounts for acuity or variation, which are additional complicating variables. Sometimes this means seeing fewer is seeing more, making Dr. Discrete Time right on occasion–but that’s another story.

Nevertheless, how departments decide to model has an effect on human behavior as demonstrated by Dr. Discrete Time and Dr. Continuous Time. Unintended consequences occur when suboptimal models are used, as human behavior has a way of working around traditional modeling methods. Models are static constructs. Human behavior is dynamic. This is the very problem.

We also must remember that we call it a “model” because it isn’t reality. If it were reality we wouldn’t call it a model. We’d call it…reality.

Although we assume that modeling emergency department flow and behavior is a simple process, in reality, pioneering this field of measurement is quite complex. So for now we simply measure what is easiest to measure.

I discussed this dichotomy in greater detail in a recent article in Emergency Medicine News entitled, “Moneyball in the ED.” The article provides a glimpse into new paradigms we need to explore regarding efficiency measures.

As for the differences between discrete time and continuous time modeling, we need to be careful what we ask for, as we just might get it.

Phillip Stephens, DHSc, PA-C, is the associate practitioner site director for Emergency Medical Associates at Southeastern Regional Medical Center, Lumberton, N.C. He is adjunct faculty at A.T. Still University in Mesa, Ariz., and has practiced as an emergency medicine physician assistant for more than 20 years.   

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