I recently read an article about reducing physician burnout written by a health care consultant who proposed the creation of an enhanced medical scribe, or “team care assistant” (TCA). According to the article, the TCA obtains the patient’s medical history through “template-driven questions about the chief complaint.” After obtaining the history, the TCA then calls the physician into the exam room to present their findings. The article describes it this way: “The 5 to 15 minutes of data collection is then presented in a 2 to 3-minute crisp, data-packed presentation to the physician in front of the patient.” Wait, what? This sentence, stated so cavalierly, epitomizes the disconnect between health care administrators and physicians, who spend years honing the skills that appear so simple to health care consultants. In fact, as I read and re-read this sentence, I had a sudden epiphany: the reason that administrators believe that physicians are so easy to replace is that what we do appears deceptively simple. Of course, as physicians, we know that the reason we make it look easy. It’s because we spent over 15,000 hours developing and practicing our skills. To paraphrase Karen Sibert, MD, who writes about her specialty field of anesthesia, our skill in making what we do seem easy has caused physicians have become victims of our own success. For those who are not physicians, let me dissect the multiple ways that administrators and consultants misunderstand the complexity involved in learning how to accurately obtain and synthesize a medical history. First, learning to obtain relevant data from patients is a foundational process that begins in the first year of medical school. The definitive textbook on the subject weighs in at nearly six pounds, and while not all 1,000 pages of the book pertained exclusively to obtaining the medical history, at least two hundred pages are dedicated to the subject. After reading and studying our textbooks, physicians-in-training practice, we interview mock patients and receive feedback, watching videos of ourselves to assess our body language. In the clinic, our preceptors assign us patients to interview, and we return to present the information we have learned — only to discover that we missed crucial aspects, like the time I explained to my senior physician that a mosquito bite had caused the blistery rash on my patient’s back. My face burned when the doctor explained to me that there was no mosquito. “This is herpes zoster,” he said with a gentle smile, explaining that patients sometimes make assumptions to explain their symptoms, and it was my job as a physician to sift through the details to deduce the truth. Indeed, this is the biggest challenge with following templates to obtain patient information. Patients don’t always know the cause of their symptoms. Sometimes they initially hold back information, especially regarding sensitive subjects like psychological issues or concerns of a sexual nature. When it comes to vague chief complaints, like fatigue or “just not feeling right,” templates may completely fail. And what about the patient with a laundry list of concerns? The article says that the TCA can solve this problem by setting patient expectations “such as by helping to keep an urgent visit to just one issue.” But what happens when the second issue is a real or more serious problem? The article also suggests that the TCA “let the patient with a list of 10 items know that the doctor will be made aware of them all but may only be able to evaluate two today,” but does not explain how the assistant will know which two templates to follow of the ten complaints. What about a patient with multiple chronic health conditions requiring attention and an acute problem? These nuances of history-taking require the skill and finesse of a physician’s training. And believe me, they are more the norm than the exception. Regarding the time savings this model is promised to generate, the article says that the TCA can “capture all the patient’s medical information” in “5 to 15 minutes.” This is highly unlikely, as physicians-in-training often spend more than an hour obtaining an initial history in the early stages. We are still learning to glean what is most important, leading to agonizingly long presentations in which we describe information completely irrelevant to the situation at hand. With feedback from senior physicians, we will begin to hone our history to just the “pertinent positives and negatives,” a skill that requires years to master. Speaking of presentations, the article uses the word “crisp” to describe the TCA’s delivery of the history not once but twice. But for those of us who have suffered through physician trainees’ early presentation attempts (our own included!) on rounds, “crisp” is the last word that comes to mind. More appropriate words would be halting, stuttering, and jumbled, requiring our attending physicians to have the patience of Job with each new class of interns. The idea that somehow a medical assistant with on-the-job training will accurately synthesize and deliver a medical history better than a brand-new physician simply defies logic. By the way, these same attending physicians would never take an intern’s presentation at face value. Rather than basing their assessment and treatment plan on the likely incomplete (and possibly incorrect) information of a newly minted doctor, the senior physician will interview the patient personally to ensure the correct diagnosis. Yet, the article presumes that a clinic physician will take the liability of accepting the information provided by a far lesser-trained individual because it will supposedly decrease “burnout?” Rather than inventing inappropriate new roles for team members to increase productivity, health care consultants would be wise to focus on the true causes of physician burnout: not enough face-to-face time with patients and unnecessary administrative burdens. While incorporating a medical scribe may help, so would returning to old models like transcriptionists, paper charts, and direct patient care. Above all, before consultants and administrators try to “solve” the problems of physicians, stop making assumptions. Instead, just ask us. Source
