Tuesday, September 18, 2007

Dumb and Dumber

One of the basic rules of management is that if you want to learn how to improve your product or service, you should ask the folks on the production line for ways to make it better. Let me give you an example.

Several years ago, a management study done at an automotive plant sought to determine why productivity had suddenly dropped. It didn’t take long for researchers to discover that management kept switching people back and forth between working three days on day shift and two nights on graveyard shift. Apparently inspired by some kind of Dilbert-like logic, a bean counter had convinced management that taking this approach would get more productive time out of the laborers!

Reality proved to be quite different: With their body clocks severely out of whack, the plant’s entire work force had been reduced to an army of zombies. Thanks to a combination of sleep deprivation and total exhaustion, employees were working slower, suffering more emotional problems and making more mistakes which compromised quality control.


Back in the days when people were still using tapes, I was one of the top producers for a large transcription company. Because of its contractual obligations, this company was desperate to get certain reports transcribed and delivered within a 24-hour time frame. With its infinite lack of wisdom, management proposed that certain transcriptionists be paid a differential for transcribing “semi-stat” reports. Their theory was that if drivers left the office at 5:00 p.m. , transcriptionists could receive the tapes by 6:00 p.m., have the transcribed work delivered via modem by 10:00 p.m. and delivered to the client on time!

Three weeks into this brilliant experiment, it was obvious that management’s theory had failed (keep in mind that the brains behind this decision worked during the day shift and had no experience transcribing). Tapes were not getting to some transcriptionists until 9:00 p.m., by which time most of the MTs were in no mood to type. Many were furious at having wasted several hours waiting for work to be delivered (nonproductive time for which they were not compensated) and then being forced to transcribe until midnight or beyond. Management’s experiment was causing them to suffer increased stress while losing money.

What went wrong? Management had focused on the wrong people’s needs. In order to keep the drivers busy -- and get them home by the end of their shift -- the company was sending them out into one of California’s most gridlocked traffic zones at the peak of the evening rush hour! Although the drivers were nice guys, their most critical job skills involved being able to park a vehicle.

Having lost patience with the situation, I hinted that management had approached the entire problem ass-backwards. Shocked that a transcriptionist would be so bold as to question authority, management challenged me to come up with a better solution.

Nothing could have been simpler! Since doctors did their greatest volume of dictation at the end of the day, I told them to have the night supervisor bundle up tapes around 10:00 p.m. and send the drivers out at midnight (when there would be no traffic on the freeways). If drivers delivered tapes to secured drop points, the transcriptionists would have work available to them first thing in the morning — when their minds were fresh and they were ready to start work. If transcribed reports could be delivered electronically by noon, the company would still be within its contracted 24-hour turnaround time and everyone would be happy.

The important thing for management to understand was that it would be much smarter to hire one or two drivers to work graveyard shift at a slightly higher pay rate than to alienate the company’s top transcriptionists whose core set of complex language skills were a critical factor in delivering a finished product on time. What happened when management tried my plan? The drivers were less stressed, the transcriptionists were much happier, productivity improved and the clients got their reports on time. What started out as a classic case of management being penny wise and pound foolish ended up with improved service — once management was forced to listen to someone (in this case a medical transcriptionist) who had a global understanding of the process.

The bottom line? It’s much easier to find someone with a driver’s license who is willing to work graveyard shift than it is to find a good medical transcriptionist.


My point is that one should never underestimate the intelligence of a medical transcriptionist.

  • These are people with strong reference skills.

  • These are people with critical thinking skills.

  • These are people with problem solving skills.

  • These are people who should not be treated as fools.

And yet frequently they are. A common ploy used by physicians to intimidate fellow members of the patient care team is to accuse others of being jealous that the physician received a better education and that he makes more money than they do. Another tactic is to suggest that a doctor, by definition, is a professional and that anyone who lacks a license to practice medicine is not. When a doctor haughtily suggests that a medical transcriptionist is jealous because the MT’s education was inferior to the physician’s, the experienced medical transcriptionist is primed and ready to ask the learned doctor this question:

“Would you please tell me why — if my education was so inferior to yours — it has become my professional responsibility to identify and correct the documentation mistakes in your work that endanger a patient’s care and make both you and this hospital vulnerable to a medical malpractice lawsuit? I’m really eager to understand this, especially since these are mistakes that you (as a doctor with such a superior education) should not be making!”


For the past decade, the medical transcription industry has been wrestling with the definition of a line. The American Association for Medical Transcription (AAMT) — which makes lots of recommendations but rarely claims to take a position on anything — recently threw in the towel and withdrew its support for the 65-character count as an industry standard.

Although AAMT has a staunch crew of loyalists, the organization’s leadership occasionally comes under attack by critics who are less interested in academic masturbation than in coping with the stressful realities of today’s rapidly-changing workplace. These critics enjoyed a hearty laugh several years ago when one of AAMT’s leaders predicted that the Internet would be a passing fad — much like pet rocks. I don’t know about you, but since that article appeared I’ve spent a lot more time on the Internet than I have petting anyone’s rocks. My own theory is that there is something dangerously wrong with the drinking water in Modesto a hotbed of methamphetamine production in California’s central valley.

Today, AAMT’s critics are up in arms about the announced goals of the American Society of Tests & Measures’ new E31.22 work group chaired by Claudia Tessier. In addition to her position as chair of ASTM’s E31 committee on Healthcare Informatics, Tessier has been the Executive Director of AAMT for more than a decade. No doubt under her guidance, ASTM’s press release about its new work group contained the following incendiary language:

"Unlike past efforts toward standardized formats, this effort will enhance rather than restrict the flexibility allowed to physicians in generating patient care documentation because they will not be required to dictate according to these formats. Rather, medical transcriptionists will be responsible for preparing reports that conform to the standards.”

Make no bones about it, folks. This kind of policy-wonking crap is developed by people whose job security and self importance rely on creating new committees and fostering studies to determine how many angels can fit on a 65-character line. These people are every bit as dangerous as the self- proclaimed geniuses who design offices and kitchens in which they will never have to work.

A practice manager at a large teaching university chuckles every time a new wave of policy — with the latest guidelines about how things should be done — arrives from the higher echelons of administration. All too often such guidelines have no basis in reality and the clinical staff (which is already under tremendous pressure) has no time to read them. What happens? These guidelines end up in a pile of paper on a shelf. Hundreds of pages of policy accomplish little more than puffing up the egos of those who promulgate such bureaucratic bullshit!

As a working school librarian, my sister frequently angers those who teach graduate-level library science courses by drawing a sharp distinction between “theory of library science” and “survival skills for managing a real library.” So I want to stress something very important in this column.

It’s been a helluva long time since the association executive chairing ASTM’s E31.22 work group was out in the field transcribing. Her proposal — which would force medical transcriptionists to act like co-dependent battered wives cleaning up after dysfunctional alcoholics — embraces the worst possible approach to the problem of creating quality documentation. Although the challenge of creating standardized formats is a big one, the required solution is to teach all healthcare providers — especially dictating physicians — how to properly produce quality documentation. This cannot be accomplished by simply foisting more legal and practical responsibilities onto the shoulders of medical transcriptionists who are already struggling to cope with substandard raw data.

Let me tell you why: If, in a medical malpractice lawsuit, a physician can insinuate that a transcribed report didn’t conform to the standards the doctor “assumed,” “imagined,”anticipated” or “expected” would be applied to his dictation, then attorneys can easily go after the medical transcriptionist who produced that report (who would then be vulnerable in the area of errors and omissions liability).

Well, excuuuuuuuuse me! Wasn’t Tessier pushing errors and omissions insurance to AAMT’s membership several years ago? After MTs failed to rise to her initial challenge, is Tessier now trying to use her position at ASTM to create a market for errors and omissions insurance?


Or are people still trying like hell to avoid the crux of the matter? What is truly needed is physician education. That means:

  • No more enabling physicians to shirk the responsibility for creating reports that measure up to appropriate standards of quality assurance.

  • No more forcing transcriptionists to claim responsibility for substandard work that could only be based on a physician’s incoherent, inaccurate and unintelligible dictation.

  • No more asking transcriptionists to work harder to earn a smaller payback while accepting more liability which would normally be covered by a physician’s medical malpractice insurance.

To quote Susan Powter: “Stop the insanity!”

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