Monday, September 17, 2007

Not Clear On The Concept

A curious phenomenon takes place in retirement communities across America. When a man’s wife dies, the widower is often eager to remarry. When a woman’s husband dies, the widow is often content to remain alone. The most common explanation? “I spent too many years cooking and cleaning for that man. In whatever time I have left on earth, I have absolutely no interest in picking up someone else’s underwear!”

“Bitter? Party of one?” Not really. Communication is a key ingredient in the health of any long-term relationship -- and failure to communicate can lead to big problems. I became acutely aware of this when one of our transcriptionists developed the flu, requiring me to pinch hit on two long-time accounts. I ended up listening to several chronic mumblers – men I have repeatedly warned that if we cannot understand or even hear what they are saying, then there is no way in hell they can expect to receive a coherent medical report.


Mumblers cause a particular problem for transcriptionists that is invisible to management. One doctor dictates at the end of the day when he is tired, his voice is fading, and it drops to a whisper. Another likes to dictate through a speaker phone (despite numerous requests that he not do so) or while standing under the public address system in an airport. The third has a nasty habit of not speaking into the microphone and mumbling at the same time!

Most dictating physicians pay little attention to the quality of sound in their dictations. But compromised sound (whether from someone’s muttering or his refusal to speak into the microphone) causes a very specific, labor-intensive problem for the transcriptionist -- who must constantly replay tiny increments of dictation multiple times and struggle to hear something that can be transcribed into text. If a dictator is mumbling, it can take double, triple -- sometimes five times the usual length of time required to transcribe a report. By the time the medical transcriptionist finishes that report, there is a heightened sense of rage and frustration which undercuts productivity.

A transcriptionist’s loss of productive time from struggling through acoustically compromised dictation leads to a diminished volume of transcribed reports during the course of a work shift. Whether measuring by the line, the minute, the page, or any other criteria, diminished productivity leads to decreased earnings and -- with some MTSOs -- the possibility that the medical transcriptionist will be penalized for failing to meet stated productivity goals. This means that if a transcriptionist hits a bad string of mumbled reports, she risks being financially punished -- for no fault of her own – simply because some doctor couldn’t be bothered to speak clearly.

Let me give you a very specific example of how this works. One of our clients recently started using a digital handheld recorder (which offers him the flexibility of not having to dictate over the telephone). He’s a nice guy whose level of computer literacy is nowhere as high as he would like to believe it is. Like many physicians, when something goes wrong, his immediate impulse is to say “This is not working. I can’t do it. This is taking up too much of my valuable time!”

Said doctor recently uploaded a dictation that clocked in at 155 minutes, which seemed like an extraordinary length of time for one of his reports. The transcriptionist had to listen to the entire sound file to find out what this was all about. And guess what she discovered? The good doctor had somehow managed to jam the “record” button into the “on” position before putting his digital handheld into his pants pocket. As he kept talking to people in his office, the voice-activated handheld device kept recording random noise. With stunning clarity, it captured the mellifluous sounds of the physician urinating and then went on to record the rest of his afternoon in the office. But the transcriptionist, who has been doing his work for years, still had to listen to the entire sound file to make sure he didn’t start dictating another report.

If a physician were confronted with surgical instruments caked in mud each time he went to operate on a patient, there would be hell to pay (and not just for the loss of sterile technique). The sheer loss of billable time would have a surgeon foaming at the mouth! Doesn’t a transcriptionist deserve to be paid for her professional time? And isn’t this incident the result of nothing more than carelessness on the part of the physician?

I mention this because time is money. And lost time is lost money. Brenda Hurley’s ASTM committee has hopes of distributing standards for proper dictation techniques to physicians. However, my gut tells me that it will be very hard for doctors to break their old habits. Who gets the short end of the stick in these situations? The transcriptionist, of course.


The same week I got reacquainted with Dr. Mumbles, I received a frantic call from one of our clinics asking how they could calculate the number of lines of dictation for the coming year. Since this account has been paying by the minute of recorded dictation time for approximately seven years, I was a bit nonplussed as to why they wanted to know how many lines to budget for. As I discussed the situation with the clerk who had been given the task of researching this question, I realized that some people never get the message.

In his blind desire to get a fixed number, the clerk had no understanding whatsoever that new healthcare providers who joined the clinic’s staff and started dictating reports would have an impact on his budgeting projections. Nor did he grasp that some doctors dictate longer reports than others. Or that some physicians (who dictated extremely long reports) had moved on to other jobs in other cities – thus wrecking his line count projections. All he wanted was a number. Its accuracy or relevance didn’t seem to impress him.


Despite being marketed as the long lost panacea for problems with dictating doctors, new electronic toys and advanced technology can’t solve basic problems caused by human carelessness and/or stupidity. As more and more digital handhelds enter the marketplace, more doctors have become eager to acquire a device which will allow them to dictate while on the move. The freedom to dictate without being tethered to a phone allows them much more flexibility in their daily routine. While some physicians (who are always paranoid that vendors are trying to rip them off just because they’re doctors) resent paying higher prices for new technology, others want the newest gimmick as soon as possible. There’s just one problem.

New products often come with mini-manuals which are poorly written and omit critical pieces of information. In recent years, a noticeable trend has been for more and more software upgrades to be issued with less and less documentation. We learned this lesson the hard way when we first ordered an Olympus digital handheld for one of our clients. When we asked our vendor for help in facilitating file uploads, we ran into a classic case of the marketing staff not knowing what the guys in technical support already knew to be true.

With the first physician to move to a digital handheld, we discovered that the software’s installation program worked fine with Windows 98, Windows NT, and Windows XP. But it would not cooperate with Windows ME (which, of course, was the operating system our client had on his laptop). It took a good 24 hours – and one disgruntled orthopedic surgeon – before we could get that matter solved by having tech support walk us through a manual installation of the software.

In another instance, we ran up against the kind of critical oversight that makes you want to kill a vendor. After having gotten several physicians up and running with their digital handhelds, we took on a new client who was dissatisfied with the poor quality of transcribed reports he had received from a firm that was obviously outsourcing work to India. The software installation process came to a crashing halt with no explanation in sight. Numerous attempts to install, reboot, uninstall, and reinstall the software failed to produce the desired effect. It wasn’t until late in a conversation with the vendor’s technical support gurus that someone dropped a little bomb of information technology trivia.

“Did you say this doctor is on an NT platform? That’s probably why the sound files won’t move from his handheld to his office computer. The software is USB compatible, but Windows NT is not. Didn’t anyone tell you that?”

Um...arrgh....NO!!!!! But thanks for sharing.

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