Medical Scribes: A Pro or a Con in Pain Management and Anesthesia?

​Summary:  

The use of medical scribes to handle computer-related tasks is rapidly growing in medicine. Should pain management and anesthesia practitioners use scribes? We explore the arguments for and against this growing trend.

Though a recent Mayo Clinic survey of 5,400 physicians shows burnout has dropped slightly and satisfaction with work-life integration has risen somewhat across most specialties, including anesthesiology, burnout still pervades healthcare and is considered a major public health problem. For some, healthcare's Triple Aim has become the Quadruple Aim, with a goal for clinicians of "attaining joy in work."

Physicians still report higher burnout rates than the general population. The stress induced by electronic health records has been well-documented as a major cause. In response, a growing number of physicians are turning to medical scribes to help ease the administrative burden of EHRs and free themselves to focus more on clinical care and face-to-face interaction with patients.

Though responsibilities vary, medical scribes are trained assistants who work alongside clinicians, handling their computer-related tasks, often in real time. Some scribes, but not all, are pre-med or med students looking for exposure to clinical settings.

"The fix is, admittedly, sort of ridiculous," Atul Gawande, MD, MPH, wrote recently in the New Yorker. "We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we're hiring more humans. And it sort of works." As one emergency room physician put it in an article in the New York Times, "With a scribe, I can think medically instead of clerically."

Are medical scribes a good fit for pain management practitioners or even anesthesia clinicians? Our sense is that they could be, but we encourage clinicians to carefully weigh the benefits and possible pitfalls, starting with the information provided here, before deciding whether to go down this path.

Many physicians are going down this path, and an entire medical scribes industry has sprouted as a result. The American College of Medical Scribe Specialists offers licensing, certification, credentialing and continuing education, and estimates that the number of medical scribes is doubling annually, with about 100,000, or about one for every nine physicians, expected to be working by 2020.

In an article on The Doctors Company's website, Jeffrey A. Gold, MD, of Oregon Health Sciences University (OHSU) calls medical scribes "the fastest growing medical field," with reports of scribe use in almost every setting across most specialties, despite a lack of standardized training. Our informal review of the job site Indeed.com showed several position listings for medical scribes posted by pain management practices.

Depending on which site you visit, pay for medical scribes ranges from $13 to $18 per hour to $20 to $25 per hour. Glassdoor estimates that medical scribes earn an average base pay of about $25,000 per year.

The scientific literature suggests scribes may decrease clinician time with EHRs and free time for leadership, personal and other pursuits. Scribe use has increased the number of patients seen per hour, increased the number of relative value units (RVUs) per hour, decreased physician overtime, increased net revenue without affecting patient satisfaction and increased productivity(generating additional revenue of $1.3 million at a cost of $98,000 in one cardiology clinic). Other studies have shown that scribes were able to reduce documentation time and enhance clinician satisfaction by allowing doctors to focus more on their patients, and increase emergency department efficiency and enable physicians to use their skills more effectively.

In contrast, though medical scribes helped improve productivity and satisfaction and lower stress among physicians in one qualitative study, some physicians "were concerned about losing important nuances and cognitive processing time for the case." Another study showed a small but significant decrease in patient satisfaction with the use of medical scribes, while another revealed no evidence that scribes reduce patient satisfaction or increase discomfort that might cause a patient to withhold information.

In a 2015 JAMA Viewpoint article, medical informatics specialist George A. Gellert, MD, MPH, MPA, of Christus Health observed that by providing an effective workaround, the use of medical scribes could reduce market demand and pressure on the technology industry to develop better solutions, creating "an unintended, undesirable outcome: a deceleration and possibly stagnation in EHR technological improvement."

OHSU's Dr. Gold said that some healthcare providers also are worried about "'functional creep'—scribes being granted the authority to perform more complex functions in the EHR over time," such as order entry, data finding, data interpretation and entering of data elements in addition to general notes—that could affect the quality and safety of care.

Dr. Gold's article was published in 2017. The following year, the Joint Commission, which states that it neither supports nor prohibits the use of scribes, issued guidelines for documentation assistance provided by scribes covering potential quality and safety issues, minimum competency recommendations, and policy and procedure considerations, among other things.

The Centers for Medicare and Medicaid Services (CMS) does not pay separately for medical scribes and does not offer official guidance on the use of scribes, but policy published in 2017 details signature requirements when scribes are used by a physician or nonphysician practitioner.

For more information, we recommend the article by Adam Landman, MD, of Brigham Health, "Medical scribes let the doctor focus on you."

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