Wednesday, September 26, 2007

Shooting Blanks

Long before people discovered recreational drugs like speed, heroin, and crack cocaine, there was a friendly little game called Russian Roulette. A simple little affair in which two dueling participants held guns to their temples and pulled the triggers to see what could happen, Russian Roulette did not ask players to worry about logging triple word scores, passing GO, or collecting $200. Why not? Because the game ended rather abruptly. If a real bullet was in the chamber of a participant’s weapon, he would blow his brains out, ending his life with a savage √©lan. If the chamber was empty, he’d hear a nerve-rattling click but live to tell about it.

Back in the 1970s, while there was still some glamour to be found in the drug revolution, people mixed recreational drugs with dexterity and panache. Oh, for the good old days when hemostats were popular as roach clips and my roommate the scrub nurse would bring home LSD that had been made in the hospital’s lab! I can still remember my roommates heading out for a Saturday night on the town with their party pillboxes stashed in their jeans. The one who had done the most drugs took care to memorize which compartments held which pills in case he became too wasted to see clearly. “I’ll take this one when I leave home so that by the time I get to the disco I’ll be starting to feel a buzz. That should keep me dancing until about 2:00 a.m.,” Chuck explained. “I’ll probably drop a Quaalude after that and head to the Barracks. By 4:00 a.m. I’ll want to mellow out a little so that I don’t crash too quickly, so I’ll take one of these little blue ones – they’re really cool. And then, when I get home after a good night of partying, I’ll take a Valium to help me get to sleep!”

Thirty years ago (long before the circuit crowd was falling into K-holes) it was disheartening to come home from work and find a group of hospital workers seated in the living room with buckets beside their chairs because they had just tried some Ketamine and were all nodding out. I still remember riding in a van filled with budding young physicians, lawyers, and hospital workers who had all dropped acid shortly before entering Disneyland. As we passed the scene of an automobile accident, reality bit hard as the physicians in our van realized that they were tripping too much to be able to stop by the roadside and offer their help as doctors. Hippocratic oath and all that stuff, you know. First, do no harm. Then light up another joint.

In those days, there were so few concerns about drug interactions that it usually wasn’t until someone overdosed that people started to worry about mixing pills. Since then, partying has gotten even riskier. These days, far too many people get dehydrated while tripping on Ecstasy and collapse on dance floors across America. Not only has the quality of drugs become more suspect, the sheer stupidity which allows someone to lace a potential date’s drink with GHB boggles the mind.

I mention these gruesome facts because, in recent years, the media has focused attention on the topic of medication errors -- and how they relate to wrongful deaths. New technologies are bringing some wonderful devices to market that can prevent a physician’s illegible scribbling from accidentally killing a patient. Some physicians now use Palm Pilots which allow them to point and click their way through a drug database. Such handheld devices can ensure that the spelling and dosage of the medication being prescribed are accurately linked to the patient’s name before that data is sent to the pharmacist. Meanwhile, the pharmacy’s database can cross-reference the medications in a patient’s prescription history to warn for any dangerous drug interactions.

Gone are the days when MTs were forced to thumb through dog-eared Xeroxed copies of quarterly drug lists (whose print was so tiny -- and so horribly blurred -- that a person could barely make out the capital letters). Today’s medical transcriptionists can easily integrate formidable software programs like Medical Drug Index and the Quick Look Drug Index’s electronic edition into their word processors. Not only do these programs offer a ton of information on each medication currently on the market but, with the click of a mouse, they can deliver the proper pronunciation of the drug through the computer’s speakers. In addition to the wealth of reference tools to be found online at, powerful search engines are available for any MT to use.

With so many technological blessings and cross-indexed databases, what could possibly go wrong? The same thing that always gets in the way – physicians with poor dictation skills. That means:

  • Physicians who mumble or dictate drugs whose names cannot be documented.

  • Physicians who, when they are too tired to think straight, like to invent new medications that sound like what they really meant to prescribe.

  • Physicians who say “didj” without specifying whether they want the transcriptionist to type Digepepsin, Digess8000, Digibind, Digitaline, digoxin, digitoxin, or digoxin immune.

Amazingly, these licensed creators of a patient’s medical record assume that a medical transcriptionist – or even worse, a speech recognition engine – has sufficient powers of clairvoyance to understand what a dictating physician meant to say even when he failed to coherently communicate his thoughts.

Sorry, folks. But that’s just not how transcribing works. One of the cardinal rules of medical transcription is that if an MT cannot understand what a physician is saying, then there is an ethical -- and legal -- responsibility to leave a blank space so that the dictator can insert the proper terminology when proofreading the report. (Of course, that guideline assumes that the physician will even bother to read his own transcribed reports!) I stress this because, as more and more entrepreneurs have entered the field of medical transcription, seasoned MTs keep hearing demands for fewer blank spaces in their work product.

The goal of proofreaders and quality assurance people should not be to chastize and punish the transcriptionist who cannot understand what Dr. Mumbles has failed to communicate. It should be to make sure that the correct information gets into the patient’s medical record. This is the critical point where medical ethics often collide with financial goals.

“I don't believe in adding diagnoses just because someone left it empty -- in fact there have been times when doctors have left something empty for very specific reasons,” notes a veteran transcriptionist. “The bottom line is that the push for MTs to add this information is motivated by greed, not clinical precision. Hospital administrators are trying to speed up reimbursement from third party payers.”

If a transcriptionist can use the Internet to get advice from colleagues on a medical term that “sounds like” something and may possibly make sense, that’s one more piece of ammunition in her arsenal. But when push comes to shove, a transcribed report can only be as good as the raw materials which go into creating it. The physician not the medical transcriptionist – carries the legal responsibility for accurately rendering diagnoses and prescribing medications. A good transcriptionist will try to catch as many errors as possible when the physician fumbles while dictating reports. But as eager as some MTs are to show off their knowledge, there is a line that should never be crossed. That line is called “playing doctor.”

Newbies are sometimes carried away with trying to show how much they know. Veteran transcriptionists have been correcting physician mistakes for so long that they “assume” it is their responsibility to fill in what the doctor really meant to say. And some physicians have gotten too spoiled by their rescue efforts. I still remember listening to a surgeon scream “Why are you typing what I say instead of what I mean?”

“Here's a simple solution,” suggests one MT. “If they want you to make like a doctor, make them pay you like a doctor. Since they're always complaining about the high cost of transcription, tell them that you'll consider doing this if you are paid $100 per diagnostic call and are given a signed statement from risk management assuring that you will not be held liable for any claims of medical malpractice. If they don't like it, then they can tell the doctor to do his own work (like he's supposed to). After all, the medical license is covering his ass, not yours.”

During World War II there was a popular saying: “Loose lips sink ships!” If a rallying cry of equal gravity should become a standard within the medical profession, it would be “False saves dig graves!” Leaving multiple blanks in a transcribed report may not result in a cosmetically appealing work product. But it might just save a patient’s life.

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