Abstract
Purpose: The immense clerical burden felt by physicians is one of the leading causes of burnout. Scribes are increasingly being used to help alleviate this burden, yet few published studies investigate how scribes affect physicians' daily work, attitudes and behaviors, and relationships with patients and the workplace.
Methods: Using a longitudinal observational design, data were collected, over 1 year, from 4 physicians working with 2 scribes at a single academic family medicine practice. Physician experience was measured by open-ended written reflections requested after each 4-hour clinic session. A data-driven codebook was generated using a constant comparative method with grounded theory approach.
Results: A total of 361 physician reflections were completed, yielding 150 distinct excerpts; 289 codes were assigned. The 11 themes that emerged were further categorized under 4 domains. The most frequently recurring domain was clinic operations, which comprised 51.6% of the codes. Joy of practice, quality of care, and patient experience comprised 22.1%, 16.3%, and 10.0% of the codes, respectively.
Conclusions: Our study suggests that integrating scribes into a primary care clinic can produce positive outcomes that go beyond reducing clerical burden for physicians. Scribes may benefit patient experience, quality of care, clinic operations, and joy of practice.
Burnout among US physicians is a serious and growing problem with profound implications for society.1 More than half of all US physicians are experiencing professional burnout, and family physicians have one of the highest rates of burnout among the specialties.2 A major contributor to burnout among physicians is growing workload outside of the examination room.3⇓–5 For every hour physicians spent in direct contact with patients, 2 more hours are spent on electronic health record (EHR) and desk work.6 Many physicians document only brief notes during a clinic visit, leaving most of the charting to the end of the day and spending 1 to 2 hours each night working on the EHR.6
To decrease the clerical burden felt by physicians, many US hospitals and clinics have adopted the use of scribes.7 Scribes are nonlicensed individuals trained to document patient encounters in real time under the direct supervision of a physician.8 Scribes assist with charting, recording laboratory and radiology results, and supporting physician workflow with EHR data entry.8 The popularity of scribes in the United States has risen sharply recently, and at least 22 companies are recruiting, training, and providing scribes to physicians.7 The number of scribes has been doubling annually; it is estimated that by 2020, there will be 100,000 scribes in the United States, or 1 scribe for every 9 physicians.7
Despite the rapid uptake of scribes in US hospitals and clinics, little is known about how scribes affect the daily work of physicians, how they fit into the dynamic interactions between physicians and patients, and how they change relationships and team structures in established practices. Existing studies of scribes are few and offer very limited qualitative data.9,10 Few studies have explored the perspectives of physicians, scribes, and patients regarding scribes in primary care.11,12
To our knowledge, no longitudinal observational study of scribes has examined their impact on physicians' daily work, attitudes and behaviors, and relationships with patients and the workplace. Our aim was to explore these questions through an ethnographic study of physicians and scribes in an academic family medicine clinic, using repeated observations and data collection over 1 year. Our objective was to identify challenges and opportunities resulting from physicians and scribes working together as they relate to patient experience, quality of care, clinic operations, and joy of practice.
Methods
Design
The study was conducted from July 1, 2015, to June 30, 2016, at a single family medicine clinic associated with an academic medical center in California. Four physicians and 2 scribes participated in the study. All physicians were board certified in family medicine, with a mean of 6 years of experience; none had prior experience with scribes. All 4 physicians were faculty clinician-educators with a clinical full-time equivalent ranging from 0.5 to 0.75. Both scribes held baccalaureate degrees and completed an 80-hour training course administered by a commercial company (Elite Medical Scribes, Bloomington, MN).
The qualitative data used in this research were collected as part of a larger randomized controlled study of scribes, described elsewhere in the literature.13 Physicians were assigned a schedule of 1 week practicing with a scribe alternating with 1 week without a scribe. During the weeks when the physician was assigned a scribe, the scribe attended all patient encounters alongside the physician and drafted all relevant documentation, including the patient history, objective examination findings, assessment and plan, and patient instructions. The physician was required to review all scribed notes for accuracy before signing/closing the chart. During the weeks when the physician was not assigned a scribe, the physician was responsible for all charting. The outpatient version of the Epic EHR (Epic Systems Corp., Verona, WI) was used.
Survey
Physician experience was measured by a self-administered questionnaire that included a free response section in which they were asked to record observations about their clinic experience. Physicians were offered 1 questionnaire after each 4-hour clinic session throughout the 1-year study period. This approach allowed physicians to record “just-in-time” observations akin to keeping a diary, following the principles of ethnography.14 Entries had no word limit restrictions and could be completed any time after each 4-hour clinic session. If an entry was left blank after a week, an automatic reminder was sent to the physician, inviting him or her to complete it.
Coding
A codebook was developed using a constant comparative method with the grounded theory approach.15 Three reviewers (AS, TR, SL) identified and defined the recurring themes from the surveys using a data-driven methodology, with triangulation from the literature. The codebook was iteratively refined until the final themes were unanimously agreed on (Table 1).
Codebook Developed for Qualitative Data Analysis
All physician entries were transcribed into Dedoose (version 7.0.23), a web-based qualitative data analysis software. Using Dedoose, 2 coders (CN, SL) independently reviewed each survey and identified the relevant excerpts, labeling each comment with ≥1 code according to the codebook. The content units for data analysis were words and phrases. Interrater agreement was analyzed. The coded units were then grouped based on categorical themes/domains. The coders were blinded to the authors of the entries.
Institutional Review Board Approval
This study was exempted from formal review by the institutional review board of the Stanford University School of Medicine.
Results
Over the study period, a total of 361 physician reflections were completed, yielding 150 distinct excerpts with 289 code assignments. Physicians completed 73% (361 of 494) of the surveys offered. Two physicians contributed equally to 88% (316 of 361) of the completed surveys; the other 2 physicians returned 12% (45 of 361). Eleven recurring themes emerged, which were further categorized under 4 domains: clinic operations, joy of practice, quality of care, and patient experience (Table 2).
Identified Themes and Domains with Representative Physician Comments
The most frequently mentioned domain was clinic operations, which comprised 51.6% (149 of 289) of the codes. The other 3 domains—joy of practice, quality of care, and patient experience—made up 22.1% (n = 64), 16.3% (n = 47), and 10.0% (n = 29) of the codes, respectively (Figure 1). Interrater agreement was established between the 2 independent coders with a κ value of 0.72.
Distribution of Coded Physician Comments in each domain (n = 289).
Clinic Operations
Themes under this domain included charting efficiency, clinic operations, EHR, extension of the scribe role, and non-patient-facing work. The majority of comments in this domain was positive or neutral (66%; 98 of 149); almost all the negative comments (34%; 51 of 149) were related to operational inefficiencies (eg, “poorly booked clinic” or “patient refused the scribe”) or dissatisfaction with the EHR that had nothing to do with scribes. Physicians expressed high satisfaction with efficiency of charting when a scribe was present, and appreciation when their scribes helped them with work beyond documentation support (eg, completing paperwork and forms, drafting letters, assisting with procedures).
Joy of Practice
Themes under this domain included teamwork/partnership and quality of life. The vast majority of comments was positive or neutral (94%; 60 of 64); all the negative comments (6%; 4 of 64) were related to unfinished work that had to be done after hours, not related to the scribes.
Quality of Care
Themes under this domain included charting style and charting quality/accuracy. The majority of comments was positive or neutral (60%; 28 of 47). Most of the negative comments (40%; 19 of 47) described minor documentation errors made by scribes, nearly all of which occurred in the first several weeks of the study when the scribes and physicians just started working together. Later comments were unanimously positive.
Patient Experience
Themes under this domain included connection with patients and patient satisfaction; 100% (29 of 29) of the comments were positive or neutral. Physicians appreciated having a “deeper level of intimacy” with patients and being able to pay “more attention to body language” when they did not have to look at the computer. A few comments expressed ambivalence with scribes being in the room for sensitive discussions (eg, intimate partner violence), although they still ultimately wanted the scribe present during those difficult conversations so that they could focus entirely on the patient.
Discussion
To our best knowledge, this is the first study to use an ethnographic approach to determine how medical scribes affect the daily work of physicians, how they fit into the dynamic interactions of physicians and patients, and how they change relationships and team structures in the primary care setting. Our study suggests that integrating scribes into a primary care clinic can produce positive outcomes that go beyond reducing clerical burden for physicians. Scribes may benefit patient experience, quality of care, clinic operations, and joy of practice. By identifying relevant themes and domains, we have set the groundwork for future, robust qualitative or mixed-methods studies on scribes in primary care.
Clinic Operations
The majority of physician comments were related to clinic operations. Consistent with previous research, physicians enthusiastically praised scribes for decreasing charting time.9–10,13 This led to time saved during clinic hours, thus allowing for the timely completion of other administrative tasks like answering patient calls, reviewing laboratory or radiology results, and responding to staff messages. Physicians appreciated this increased operational efficiency and expressed dismay when patients occasionally declined the scribe.
Physicians expressed gratitude when scribes extended themselves beyond documentation support to help complete paperwork and forms, draft letters, assist with procedures, talk with patients about overdue preventive health tests, and compile resources for families. These actions saved the physicians time and relieved medical assistants from some clerical tasks so that they can focus on supporting physicians with the significant burden of in-basket management.16 This emerging triad partnership—physician, scribe, medical assistant—has the potential to improve physician wellness; studies have shown similar interventions that improve workflow, increase time for staff to complete tasks, and enhance teamwork can decrease physician burnout.17
One practical challenge identified was how to best navigate the EHR when both the provider and scribe are in the same section of the patient chart at the same time, a function that is not available in Epic and other EHRs.
Joy of Practice
Physicians described the partnership with their scribe as a “great psychological benefit” to their daily experience; having a partner with whom they could share difficult or emotionally charged encounters made them feel “less isolated” during the clinic day. Providers reported rediscovering a joy in practice as a result of working with scribes. They frequently had a healthier perspective going into work and a more relaxed attitude after clinic hours were over because they were less mentally burdened by the thought of charting. They expressed great satisfaction with having more time to spend with their families.
Quality of Care
Physician comments related to quality of care focused on the completeness and accuracy of notes generated by scribes. Physicians reported high satisfaction with both the quality and accuracy of scribe documentation. They appreciated when the scribe took the time to learn and replicate their personal charting styles. Many physicians reported a decreased “sense of dread” when presented with a highly complex patient with multiple concerns, because they trusted their scribe to capture all the important details that they would have forgotten if they had to write the note themselves at the end of the day. This finding is consistent with a study demonstrating that scribed notes are of higher quality than physician-only notes.18
Some physicians expressed concerns about minor inaccuracies in the notes generated by scribes. This is of particular relevance in the context of OpenNotes, where patients are able to review their notes online.19
Patient Experience
Physicians generally praised the scribes as a way for them to bond with their patients, focus more on patients' nonverbal cues and the natural flow of conversations, and avoid excess attention on the computer screen during visits. One study demonstrated that primary care physicians spend as much as 36% of a clinic visit navigating the HER, which reduces eye contact and directs attention away from the actual patient.20 The experience of our physicians is consistent with that in a recent study involving scribes in the primary care setting, where physicians, scribes, and patients all described improved physician attention to patients when scribes were present.11
Providers reported that they could spend more time on interpersonal subtleties when a scribe was present in the examination room. In particular, certain communication challenges—for example, patient encounters performed in another language by a bilingual provider and conversations that involved complex family dynamics—were easier to navigate when the scribe was present, allowing the physician to focus on the conversation.
Providers also mentioned, however, that having a scribe present was not universally optimal, and that certain types of visits (eg, sensitive topics, intimate partner violence) might be better served with the provider and patient being in the room alone.
Limitations
Our study's biggest limitation is the small number of physicians and scribes, thereby restricting the generalizability of these results. However, the longitudinal nature of the study and our ethnographic approach allowed for a deeper dive into rich qualitative data. Another limitation is that because entries were optional, each physician's perspective is not equally represented in the final data set; 2 of the 4 physicians contributed the majority of the comments. Last, these results represent only the perspectives of physicians, not patients or scribes. More research is needed to better understand the impact of scribes on other stakeholders in our health systems.
Conclusions
In the era of team-based care, scribes are the newest member of the care team, yet relatively little is known about their impact on physicians and practices. Our study shows that integrating scribes into a primary care setting can benefit clinic operations, joy of practice, quality of care, and patient experience. These positive outcomes go beyond reducing charting burden and may all play a role in preventing physician burnout.
Some of our findings on the impact of scribes are well established (eg, scribes decrease charting time, make physicians happier, allow better nonverbal communication with patients); others are less obvious but perhaps more interesting (eg, evolution of scribe role beyond documentation to include medical assistant tasks, implications of scribed notes in the context of OpenNotes). Here we used an ethnographic approach to identify the relevant themes and domains to set the groundwork for future research.
The question of how primary care practices can make the economic argument for scribes remains unanswered. Thus far, much of the focus has been on paying for scribes using revenue generated by additional visits afforded by increased efficiency. If primary care physicians want to argue for scribes in their practices, we believe that the justification should expand beyond just higher visit volumes to include potential benefits in clinic operations, quality of care, patient experience, and joy of practice.
Acknowledgments
The authors thank Sang-ick Chang, MD, MPH, associate dean for primary care, and Juno Vega, RN, clinic manager for Stanford Family Medicine, for their support of the scribe program. They also thank Sylvia Bereknyei Merrell, DrPH, for her advice on data analyses.
Notes
This article was externally peer reviewed.
Funding: This study was supported by a grant to S.L. from the Pisacano Leadership Foundation, the philanthropic foundation of the American Board of Family Medicine.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/31/1/49.full.
- Received for publication July 21, 2017.
- Revision received September 19, 2017.
- Accepted for publication September 23, 2017.
