Emergency medicine is one of those specialities where physicians of all grades have to make their own notes, even the consultants. Medical and surgical bosses have juniors to scribe at the ward round, secretaries to type up dictated clinic letters, assistants to type op notes (most of the time). EM consultants, like their junior colleagues, still need to put their own pens to paper, or fingers to keyboard.
There are two general ways to make notes in the ED. You can do it whilst talking to the patient, which creates the most contemporaneous notes, allows you to use the patient’s own words, and means you can easily recant the story back to them to confirm details, though can sometimes create the impression that you aren’t giving the patient your full attention. I am a big fan of this approach, writing quickly means I can document almost as fast as I can talk. In my opinion, I forget fewer questions, meaning I can carry on with other tasks without having to return to the patient when I remember later on. It’s an approach that works well for me and my very short attention span, though only really works when I’m in a department with paper documentation. Alternatively notes can be completed after seeing the patient, when you can rearrange everything you have learnt into a sensible and concise narrative. However, writing at the desk puts you in the line of fire of technicians asking you to check ECGs, or other colleagues asking your opinion on their patients, to name a few examples. These interruptions have the potential to cause confusion in the history and examination you are trying to commit to paper, and details can be missed or altered.
I would miss doing my own paperwork in the emergency department – I write small and fast, (and reasonably legible) and my note taking helps to put my thoughts in order to make differentials and come to conclusions. However, I’m sure many of you have wondered how much quicker and efficiently you could work if you had someone to write notes for you. Maybe you even have a scribe – I know of people that do, and it seems to be reasonably popular in the US.
Scribes can help those who adopt either approach, and whether electronic or paper. They allow contemporaneous note taking, so that the clinician can focus on the patient, listening to their answers carefully rather than just planning the next question. It can be easy to miss cues from the patient when you are documenting at the same time. They also mean that time isn’t spent documenting at the nurses station, allowing a better focus on other tasks – not missing that subtle MI on the ECG you’ve been shown because you’re still trying to remember how to spell “Sjögren’s”. However, as I’ve already mentioned, sometimes you need to write the notes yourself, for those more complicated patients where writing it out helps with problem solving.
In this month’s EMJ, Katherine Walker and team from Melbourne have put together an observational study and cost analysis to determine the feasibility of training medical scribes in the ED. They took 10 trainees, put them through a 1 month pre-work course followed by 2-4 months of training and clinical sessions facilitated by emergency physicians. Only 5 trainees became competent, and required 68-118 hours of clinical work to do so. They found training scribes to be a feasible exercise, and crucially did not find any loss of productivity in the physicians who trained them. Medical students became competent more quickly than pre-med or non-medical students, and only medical/pre-medical students made it through the whole programme. There is little information on how scribes were selected to go forward to each part of the scheme, and also what the criteria were for applicants to be offered an interview. There was an overall loss in money from the programme, which had not been recuperated by the end of the study. Longer periods of observation would be needed to identify how long it would take for training costs to be outweighed by productivity savings, if at all.
As always we’d recommend you read the paper yourself to get the full results and to be able to draw your own conclusions. A reply from a senior scribe, Nicholas Rich, also provides a useful commentary and some further reading.
It’s an interesting concept, one that doesn’t appeal to me personally, but maybe it does to you. Have you got a scribe? Do they improve your productivity and patient interaction? We’d love to know.