Tuesday, September 18, 2007

Transcription's Dirty Little Secret

Last year I was contacted by a physician with a peculiar problem. He had a group of eager applicants from Eastern Europe who wanted to be enrolled as medical students in his training program at a prestigious East Coast hospital. Unfortunately,their English was so poor that they could not pass the essay requirements on certain forms and examinations in order to be approved for admission. Having studied my company’s web site, the physician asked if we could transcribe the handwriting from these applicants in such a way that they could be enrolled as medical students.

When I explained that his applicants could dictate over the phone like any practicing physician, the good doctor became rather agitated and stated that my suggestion wouldn’t solve his problem. Because of their poor language skills, these physician wannabes weren't even capable of dictating. And, as the head of this program, he thought it would be a terrible shame if their inability to speak English prevented them from being trained at an American medical school.

A basic rule of medical practice is "First, do no harm." Yet this doctor had no way of understanding that what he was proposing could endanger patients’ lives. As a highly respected surgeon who taught medical students, he was too emotionally invested in his own needs to understand that a medical student who cannot communicate with patients (or use the English language as an integral part of charting) presents a serious risk factor to the patient care team, the treating facility and -- just in case he had forgotten -- the patient.

While HIM professionals constantly check the quality of transcribed reports in order to catch transcriptionist errors, no one seems very concerned about teaching doctors how to use the English language for purposes of documenting patient care. Once someone becomes a doctor, the assumption is that a physician is so well educated that a basic lack of communication skills does not merit serious consideration.

Ask any floor nurse about that.

And then, just to use the scientific approach, grab 20 charts at random and see how easily you can decipher the notes scribbled in those charts by physicians. Keep in mind that, regardless of whether you can read the physician's handwriting, you can at least see it in its original format. And that, if a risk manager has to go to trial to defend the author in a medical malpractice lawsuit, he can always ask the doctor to explain what was written in the chart (assuming the physician can read his own handwriting).

If risk managers and physicians have trouble reading the handwritten notes in a chart, what kinds of liability are hidden in the process of converting a physician's sloppy dictation into text? Especially after that dictation has been erased. Or when a physician has marked a report "Signed but not read." Or insisted that medical transcriptionists automatically affix an electronic signature to the report and post all transcribed materials in the chart without physician review?

You might find the following statements in a patient's chart.

"The patient is using condoms as birth control pills."

"The patient is a 27-year-old mother of six who, for some reason was in the operating room, but fell asleep when it was discovered that she was pregnant at another hospital."

Or, thanks to a mistake that was dictated but not caught, a surgeon might chop off a patient's left instead of right breast.

Medical transcriptionists understand this because they constantly deal with physicians who have impaired language skills.

Unfortunately, hospital risk managers -- the people who really need to understand this-- have been kept out of the loop for as long as MTs have been transcribing medical reports.

This is due to the perversely private nature of the dictation/transcription process. Whether a physician dictates onto tapes or into a digital dictation system, the only other person who works with his dictation is the medical transcriptionist who converts speech into text. This makes the dictation/transcription process as secretive as someone stepping into a confessional booth and confiding his sins to a Catholic priest. Because confidentiality plays a major factor in this process (and a great deal of work is outsourced to third parties whose contracts forbid them from contacting the dictator), there is little room to criticize the quality of raw material delivered by physicians to the highly trained ears of professional medical transcriptionists.

Most people assume that anyone who has managed to become a doctor can produce a coherent sentence. The hard truth is that we live in a society where the proper use of language has become so devalued that many powerful people who make tons of money (attorneys, physicians and corporate executives) remain functionally illiterate. While they can communicate in an abbreviated profession-specific "code," many cannot produce a “fully-formed” sentence.

Many also contradict themselves in their dictation. No matter how steadfastly MTs struggle to position themselves as "medical language specialists" (as opposed to entry level typists), it is often difficult to get a physician's dictation to make sense.

When workers use substandard raw materials in the construction industry, they endanger lives. When doctors with impaired language skills cannot properly communicate their thoughts in English, they end up providing substandard data which can endanger a patient's life.

Why does no one else know about this? Because most people examining medical records are looking at printed text and not listening to sound. They cannot begin to understand how much editing is necessary to clean up dictated text and correct a physician’s mistakes before the data gets into the chart.

The words and numbers which go into a medical chart are the raw materials which form the building blocks of a legal record. Unlike court reporters,who must transcribe what they hear verbatim, MTs play a covert word game whose goal is to eliminate the linguistic "rings around the collar" that are found in dictated medical reports.

Recently, I invoked a crude analogy while explaining this to a business networking group at the San Francisco Chamber of Commerce. As much as I despise MTs being portrayed as "the handmaidens of medical transcription," I asked everyone in the room to think back to the last time they had done their laundry. I explained that, just as maids and people who do their own laundry are aware of tell-tale stains in their underwear (from dried urine, semen and fecal material), medical transcriptionists must constantly go the extra distance to ensure that the "bacon strips" in a physician's dictation do not show up in the patient's chart.

When I used that term, a corporate consultant in the group turned ashen. After my presentation, he took me aside and whispered, “I’ve heard you speak about your company on numerous occasions, but today I truly understood the importance of what your people do."

Would someone please explain this to hospital risk managers?

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