K-K-K-Katie

Those who enjoyed the film Shakespeare in Love will no doubt recall the young playwright’s trials and tribulations in creating one of the greatest love stories of all time. ScreenwriterTom Stoppard had plenty of good material with which to construct a cinematic comedy of errors. But what some may forget is that, as an award-winningplaywright (Rosencrantz & Guildenstern Are Dead, The Real InspectorHound, Hapgood, The Real Thing and Indian Ink), Stoppard is all too familiar with everything that can -- and does-- go wrong in the process of creating a play and getting it onstage before an opening night audience.

As young Will Shakespeare tries to cope with the closing of the theater where his play is to premiere, his beloved Viola’s impending departure for America, and the fact that the actor slated to play Juliet has lost his voice, the audience endures one carefully constructed moment of suspense after another. One challenge facing Shakespeare is particularly painful for medical transcriptionists to watch. It occurs at the very beginning of Romeo & Juliet’s world premiere, when the actor chosen to speak the prologue opens his mouth. At that dreaded moment, the tension backstage (as well as in the movie audience) is almost unbearable. Why? Because the actor chosen to speak the opening lines of Shakespeare’s daring new play is cursed with a speech impediment – a dreadful stutter that could ruin the entire evening. And no one can help him get the words out of his mouth.

Sure, you say. All’s well that ends well. But medical transcriptionists who listen to dictating physicians with speech impediments face a peculiar challenge which very few people in the healthcare industry understand. It’s hard enough to concentrate on medical terminology and sentence structure when you’re transcribing dictation from someone with a normal speech pattern. But add a speech impediment to the dictation from a physician with an extremely shrill nasal tone (who sounds a bit like actor Gilbert Gottfried hopped up on methamphetamines) and the transcriptionist must battle an occupational handicap which pushes concentration to the limits, maximizes stress and can ruin productivity.

There are three basic types of dictating physicians whose speech impediments can drive a medical transcriptionist up the wall: the whistler, the stutterer and the nervous dictator who is constantly making false starts.

THE WHISTLER

Imagine the sound of chalk scratching against a blackboard. Then imagine that sound going straight into your ears courtesy of a highly-sensitized microphone. One five-minute report from a physician with a whistling “S”can leave an MT who is an adamant nonsmoker desperately searching for a cigarette.

Carol Channing used to perform a brilliant comedy sketch which was made even funnier by her deadpan delivery. The original cast album of Show Girl (Forum LP# 9054) contains a recording of “The Inside Story” in which Channing describes what happened to a fictional and long-forgotten silent film star. Enunciating with painful clarity – and a superb whistling “S” – Channing would address the audience and say “My name is Cecilia Sisson. S-i-s-s-o-n. Sisson. I used to appear opposite such greats as Wallace Beery and C. Aubrey Smith.” As the sketch continues, it becomes obvious that Sisson’s career crashed and burned as soon as talkies took over Hollywood. “Cecilia, old girl,” sighs Channing (as her whistling “S” highlights every sibilant sound), “You could have been a major star -- if you’d only kept your big mouth shut!”

THE STUTTERER

Someone with a true stutter tends to spray a lot of sound into the telephone as he dictates. This causes two problems for medical transcriptionists. First, is the feeling that you really want to get out some Q-Tips and dry your ears once the doctor has finished dictating. Then, of course, there is the struggle as one waits for the stutterer to get the word(s) out of his mouth. While this may seem like a trivial complaint to those who do not have to listen to stutterers on a professional basis, working with a stutterer really slows down productivity and leads to a diminished line count. If you would like a good example of what this experience is like, rent a videotape of My Cousin Vinny (starring Joe Pesci, Marisa Tomei and Ralph Macchio), and pay careful attention to Austin Pendleton’s bravura performance as the public defender with a horrific stutter who attempts to question witnesses on behalf of the defendants. While Pendleton is spraying the jury with saliva, think about how many words per minute he is saying – and how his speech might impact a medical transcriptionist’s productivity.

FALSE STARTS

There is a musicality to spoken language which, when one communicates properly, cues the listener in such a way as to showcase when a thought or sentence is supposed to end. This is done with a pregnant pause in one’s speech. Or perhaps the voice drops in such away as to punctuate one’s thoughts with a wide variety of inflections and dramatic devices.

Physicians who suffer from “dictator’s oral premature ejaculation syndrome” (DOPES) frequently drive medical transcriptionists to despair. These dictators are not true stutterers. They’re usually in such a rush to get through their work that they make multiple mistakes and have to start sentences over and over again. No matter how many times one advises them to slow down -- so that they will make fewer mistakes – they can’t bring themselves to diminish their speed of dictation because (a) they hate to dictate, (b) they’re afraid they’re going to miss something more interesting, and (c) they resent the fact that dictation takes up so much of their precious time.

One of the curious things that happens to these people is that they are in such a nervous rush to finish a sentence that they can barely swallow the saliva that accumulates in their mouths. This leads to a lot of false stops in mid sentence (as opposed to at the end of a sentence), followed by a series of unnecessary false starts as they try to get back up to speed. Here is a sample of what such dictation sounds like when transcribed verbatim from a urological oncologist:

“However, I do think that given his young age and good....and good physical shape that his continence results would....would be very good. I also explained to him the risk of erectile dysfunction following surgery. Given the perineural invasion on the left....on the left side....on the ....given the perineural invasion seen on both biopsies from the left, mid and base of the prostate, I do feel that saving this nerve..... that saving his left neurovascular bundle might be..... may not be advisable. I explained that with a unilateral nerve-sparing procedure that would could approximately....that one can expect approximately a 15% likelihood of return of spontaneous erections which would go up to somewhere between 40 and 50% with sparing both neurovascular bundles.”

This jerky style of stop/start speech often results in contradictions, misplaced modifiers, and other grammatical problems. Earlier this year, I took one of my clients to lunch and explained the concept to him very carefully. “I’m an extremely visual person,” he pleaded. “Give me a picture I can work with.”

How could I resist the temptation?

“Okay, you specialize in geriatric care. A lot of your patients who are living in nursing homes have problems with urinary and fecal incontinence. You’ve got them on certain medications that try to control their bowel and bladder functions and you are carefully monitoring their diets so that, on a good day, they might even have a fully-formed stool,” I explained. “I’m trying to get you to do the same thing so that, each time you dictate, our transcriptionists aren’t mopping up your mess from the floor. All we’re trying to do is get you to aim your dictation into the bowl! Is that too much to ask?”

Funny how he had never thought of it that way!

A stop/start pattern of speech gets worse when a person cannot get the words out of his mouth fast enough to communicate a complete thought. One night I received a phone call from a young man who works for a veterinarian friend of mine. We were making plans to rendezvous for a movie, yet Jimmy’s voice kept fading in and out of the conversation. He was obviously on a cell phone. But the way his voice kept breaking up made it sound as if he was trying to communicate over some cheap piece of electronic junk instead of using a digital phone.

Imagine my horror when, after the movie, I started talking with Jimmy and discovered that the reason he had sounded so strange over the phone had absolutely nothing to do with electronics. That’s the way he talks! There is a jumble of words, a mouthful of saliva, and then, if you’re lucky, the end of a sentence. Several nights later, while dining with his employer, I asked the good doctor how he can understand his administrative assistant. “Ah, yes. Jimmy,” he chuckled. “Here’s the key. He’s 22 years old and his thoughts are racing so fast that he can usually only get out the last four or five words of a sentence before the thought leaves his brain. If you want to understand him, you have to look him right in the eye, concentrate very hard– really, really focus -- and try to imagine what the rest of the sentence should have been.”

Medical transcriptionists don’t have that luxury.