Leave No Medical Student Behind

If a mind is such a terrible thing to waste, then why aren’t more medical students taught how to dictate? These people are supposed to be the cream of the intellectual crop. Their minds are being crammed full of valuable information. Their curiosity is being honed to the point where they can absorb new material like a sponge. As they enter the most crucial years of their professional training, they are eager to acquire new skills. At least they should be.

It seems downright perverse that the mantra used so effectively by the United Negro College Fund in order to raise money for scholarships for underprivileged African Americans still needs to be beaten into the heads of the Deans of Studies at America’s medical schools. But because learning how to dictate properly is given about as much importance as taking out the garbage, it’s not too surprising to encounter residents whose courage and focus in the surgical suite quickly evaporate when they are confronted with a pile of charts.

“The first time I learned anything about dictating was when I got a call from Medical Records saying I had to do 60 charts or else my medical privileges would be suspended,” a young physician recently confided. Some residents have confessed to a morbid fear of dictation based on feelings of inadequacy because they don’t really know what to do. Others have simply found that dictation is one of those administrative chores that easily falls prey to laziness, exhaustion, and procrastination.

Here’s my question: If you were paying a small fortune to attend medical school – and could expect to be saddled with loans for the first decade of your professional career – wouldn’t you want your money’s worth? Wouldn’t you want to be fully trained to enter the workplace? Wouldn’t you want to be trained in basic skills so that you could better manage your professional time?

It sounds like a no-brainer. But if you take a survey of medical schools around the nation, I’m willing to bet that fewer than 5% are teaching medical students how to properly dictate a report. Since dictation is an activity that remains out of sight and out of mind, it’s no wonder that it so rarely makes it into the curriculum of learning how to be a physician. After all, it’s just talking into the telephone. Anyone can do that.

Apparently not. One of the critical skills a good dictator must master is how to take information from one source and communicate its essence as part of the process of documenting patient care. For most people, this is about as hard to do as walking and chewing gum simultaneously. However, some residents stumble horribly while trying to master this skill. Their fumbling is so noticeable that one worries whether they are having other problems during their residency. Sometimes, if their clumsiness is pointed out to them, they respond by attacking the messenger instead of the message. Let me give you an example.

One of our clients is a fairly large clinic at a teaching university. Each year a new team of rotating residents arrives at the clinic full of energy and enthusiasm. Each year I prepare new manuals for these residents on how to dictate the complex reports required by this clinic. I spend about 40 minutes instructing them in the proper way to dictate these reports, explain how to handle mistakes, remind them of how important it is to use the correct units of measurement, show them how to deliver the data properly, and wish them well.

Most of them have little trouble learning how to dictate these reports. In their first few weeks they may stumble a few times before they get their dictating “sea legs.” But this year I encountered a resident who I suspect simply cannot follow instructions. Even with a printout indicating all of the data fields required – and the exact order in which this data must be dictated – this resident kept omitting data fields, fumbling all over the place, and generally making a mess of the reports she was required to dictate.

The sad truth is that unless a dictator gives a transcriptionist the proper data required by such reports, no transcriptionist can fill in the blanks. A transcriptionist may insert a symbol like “??” to indicate where data is missing. But by failing to dictate a report properly, a physician initiates a chain of events which costs various members of the patient care team unnecessary time and expense. No matter what kind of turnaround time has been agreed upon, the delivery of a transcribed report filled with blanks means that that document must be set aside so that the dictating physician can make the necessary corrections. In order to do this, the physician has to go through the patient’s chart again, try to find the information that should have been dictated, indicate the corrections on the transcribed report (or enter them into an electronic file) and lose valuable time in the process. Time isn’t the only thing lost, for many doctors are more than willing to pin their own mistakes on the transcriptionist operating under a physician-created handicap. Tempers flare, resentment builds, and a toxic element creeps into the relationship between the physician and the transcriptionist.

Because of their youth and oversized egos, some residents are quick to take umbrage and assume a defensive stance by attacking the person who exposes their mistakes. “How dare you suggest that I’m incompetent!” they snarl. To which one can only quietly whisper, “But you are, Blanche, you are!”

A resident who demonstrates continued problems transposing data from one report to another may well evolve into:

• A physician whose sloppy dictation techniques threaten the quality of patient care. Those of us who have transcribed for many years know what this sounds like.

• A physician who is constantly changing “left” to “right.”

• A physician who is constantly contradicting himself while dictating.

• A physician who gets confused easily and says “Oh, wrong patient.”

• A physician who becomes extremely defensive when told that his dictation is unintelligible, inaccurate, or doesn’t make sense.

There’s just one problem. Transcriptionists are the only ones listening and paying attention to these mistakes. As more and more dictation gets run through speech recognition engines, the safety net of a second set of trained ears is rapidly vanishing from the field of healthcare information management.

In the wake of the recent space shuttle Columbia disaster, many news reports mentioned how, as more and more work had been outsourced by NASA’s management, a persistent string of vociferous safety warnings had been ignored or pooh-poohed by top brass. As sad as one may feel for the deaths of the Columbia’s astronauts, I’m willing to bet that far more patients’ lives are put at risk on a daily basis by doctors with sloppy dictation habits. The unfortunate question is: Does anybody really care?

As one veteran practice manager remarked, “Of course, it’s possible that the doctor is wrong. But what in the world makes you think that he’d ever admit it?”