As an off-cycle medical student with an extended break between the completion of my M4 rotations and the conferment of my MD, I took a job as a medical scribe to keep myself active in the clinical setting (and, it must be said, provide myself with much-needed income). I was atypical among most medical scribes, who are generally college students/graduates looking to obtain experience before applying to postgraduate medical programs, so having essentially completed four years of medical school was a great asset that allowed me to be quickly placed into training and managerial roles, in addition to my basic responsibility of writing full-sentence care notes for 1-2 dozen clinic encounters per day. The actual practice of scribing isn’t quite so easy to generalize across settings and specialties — there are roughly as many ways to scribe as there are to be a physician. Yet, a few points become clear to all of us early in our training, which essentially boils down to this: scribes are best seen and not heard, dutifully typing findings to the physician’s preference but refraining from actively participating in assessment or treatment, so as to be as nondisruptive as possible. This is understandable, of course: the patient is always the focus of the encounter, and the workload in most settings where scribes are utilized — from emergency departments to high-volume specialty clinics — demands efficient time management to ensure that both patients and physicians are mutually satisfied with the quality of the visit. Indeed, most research on the utilization of medical scribes has focused on their clinical- and/or cost-effectiveness, for which the consensus seems to be generally positive. The use of scribes has been shown to increase both the quantity of patient encounters per hour and the quality of the encounter for both patients and providers. In terms of clinical reimbursement, providers with scribes saw increases in both RVUs per encounter and RVUs per hour. Perhaps the greatest beneficiaries of the work done by scribes are the physicians themselves. A combination of ever-expanding EHR systems and increased reliance on encounter notes for billing/reimbursement has created a significant documentation burden, such that physicians spend nearly 2 hours on clerical work for every 1 hour of direct patient care. In a profession where nearly half of all physicians already experience some form of burnout, this documentation burden has further negatively impacted the ability of physicians to provide patient-centered care and maintain a healthy work-life balance. Scribes allow physicians to offload nearly all of this burden and, more broadly, avoid the hassles of navigating complicated EHRs, which generally require additional training and frequently demand a degree of technical skill that physicians trained before the EHR era often lack. While further research is needed, reviews of existing data show that physicians using scribes report increased time spent with patients; higher satisfaction with the clinic; and increased chart quality, accuracy, and efficiency even with decreased time spent charting — all while decreasing physician cost-estimate per shift, which could then translate to lower cost-of-care for patients themselves. Yet, for all the data demonstrating their benefit, there is an acknowledged lack of research focusing on the perspectives of scribes themselves — which may prompt the question of whether this documentation burden becomes any less, well, burdensome simply by having been delegated to someone else. Though scribing is frequently viewed as data entry, scribes themselves are generally aspiring medical professionals: the doctors, physician assistants, and nurse practitioners of the future. As entry-level clinical experience becomes increasingly crucial to building a competitive program application, more and more premedical students are getting their first taste of clinical medicine in a role that exists primarily to displace the most tedious responsibilities. Moreover, it can prove incredibly depersonalizing in practice. After all, the scribe is not an active participant in the provision of care — we do not examine, we do not direct the history-taking, we do not determine the differential or treatment plans and we may often be expected to remain entirely silent throughout the encounter. We simply document these so the doctor doesn’t have to. Having taken this role after completing the majority of my medical training and now having an MD behind my name, I will admit to occasionally feeling both underutilized and undervalued – a qualified medical practitioner in a role too often reduced to “glorified typist.” Like many scribes, I’m employed not by a clinic but by a dedicated scribing company that essentially rents us to clinics; while I work alongside the clinic staff, I am technically not their coworker. I have a great relationship with many of the physicians I work with closely but sometimes struggle to feel like a true member of the clinic team. I take home approximately half of the hourly rate the clinic pays for my services, and even working full-time, my income is near the US poverty threshold for single earners. While there tends to be a high turnover rate among scribes owing to the large percentage that eventually matriculate to professional school, the stagnation of medical-school and GME positions in spite of growing applicant pools has necessitated that many entry-level medical workers remain in our positions for longer than anticipated. For scribes, this means more time spent performing burnout-inducing work for sub-livable wages and no guarantee of career advancement. Even before the ongoing COVID-19 pandemic prompted an increased reliance on telemedicine and other virtual-based services, medical scribes have proven to be an effective solution to the increasing demand for digitalization and documentation of care. Research suggests that their position within general academic medicine will continue to expand. For all the value that scribes add to clinical practice, perhaps it’s time for the medical community to consider how it affirms the value of the scribes themselves. I wish to thank Dr. J. M. Monica van de Ridder for her editorial contribution and invaluable insight during the drafting of this piece. Source
