Physician Burnout - What is a Scribe?
Robert E. Van Demark, Jr., MD
SDSMA President

Last month we discussed the causes of the physician burnout epidemic. Declining reimbursement, increased productivity expectations (“doing more with less”), medical practice consolidation and increased price competition have increased the economic pressures on physicians and their practices.1 Nearly 50 percent of physicians surveyed recently report some component of burnout.2 Burnout symptoms have even been reported in medical students.3

What Can be Done to Help?

Physician burnout is a system issue. Unfortunately, most institutions assume professional satisfaction and avoiding burnout are the sole responsibility of the individual physician. There is a strong business case for organizations to invest in ways to reduce physician burnout and to promote engagement.2 Shanafelt and Noseworthy list nine organizational strategies to promote physician well-being at the Mayo Clinic:2 1) Acknowledge and assess the problem; 2) Harness the power of leadership; 3) Develop and implement targeted interventions; 4) Cultivate community at work; 5) Use rewards and incentives wisely; 6) Align values and strengthen culture; 7) Promote flexibility and work-life integration; 8) Provide resources to promote resilience and self-care; and 9) Facilitate and fund organizational science.

In that paper, the authors recommend two approaches to improve the electronic health record (EHR) experience. These include assistant order entry and documentation support.  One model uses scribes under physician supervision to help with data entry in the patient encounter. A recent review article of scribe use shows increased physician efficiency and satisfaction, increased volume of patients and increased hourly relative value units generated by the physicians.4 The second model uses advanced care team models. Qualified assistants (registered nurses, mid-level providers, nurse practitioners and medical assistants) assist with note documentation, order entry, inbox management, health coaching and coordination of care.

Improving clinician workflow (i.e., documentation) is perhaps the biggest challenge we face with the EHR. Linzer et al. have shown that clinician satisfaction is more likely to improve with workflow intervention.5

In the future, we will see more technology evolving to solve this problem. Future options might include improvements of current technology (Dragon) and new technology (smart glasses and artificial intelligence) for documentation.6, 7 I have recently seen two companies that that use artificial intelligence for improving documentation: ListenMD (www.listen.md/) and Noteswift (www.noteswift.com). Check out their web sites. While we wait for the adoption of this new technology, one practical solution to improve office workflow is the use of medical scribes. Using scribes has been shown to be cost effective, improve practice workflow, and increase clinician satisfaction.4 Athletic trainers, licensed practical nurses and certified medical assistants have all been used in the scribe role. Other practices have used pre-professional students (premed, nursing, and pharmacy) as scribes. Another option includes the use of scribe services such as Scribe America, Medical Scribe Services, Virtual Medical Scribes, or Elite Medical Services for both local and virtual scribes.

Our profession is on the verge of a manpower crisis. The American Association of Medical Colleges predicts a nationwide shortage of 100,000 physicians by 2030. In a recent survey of 17,000 medical school graduates in 2016, 13.5 percent of the graduates said they planned on a non-clinical job within three years. In 2015, Merritt Hawkins surveyed final year residents and asked, “If you were to begin your education again, would you study medicine or would you select another field?” Twenty-five percent answered “another field,” compared with 8 percent in 2006. Some of the reasons cited included “a lack of free time, educational debt, and hassle of dealing with insurance companies and other third-party payers.”8

The EHR has great potential to improve health care delivery; however, in its current form, the unintended consequences of reduced efficiency, clerical burden and increased physician burnout need to be corrected. Our risk of developing physician burnout is high; awareness of the problem is the first step. Through understanding the problem, enhancing teamwork, building a culture of appreciation, and improving organizational and practice function we can improve the practice of medicine for both physicians and patients.

Book RecommendationDreamland: The True Tale of America’s Opioid Epidemic by Sam Quinones

References

1. Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-48. 
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017; 92:129–46.
3. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes. Mayo Clin Proc. 2005;80:1613-22. 
4. Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med. 2015;28:371-81. 
5. Linzer M, Poplau S, Grossman E, Varkey A, Yale S, Williams E, et al. A Cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. J Gen Intern Med. 2015;30:1105-11. 
6. Mitrasinovic S, Camacho E, Trivedi N, Logan J, Campbell C, Zilinyi R, et al. Clinical and surgical applications of smart glasses. Technol Health Care. 2015;23:381-401. 
7. Bresnik J. Can artificial intelligence relieve electronic health record burnout? HealthIT Analytics. 2017;12:1-3. 
8. Doctors without patients. Business Week. 2017 Sept. 11:34.