Tuesday, July 14, 2015

The Doctor Has the Power

Doctors protect our health. Doctors can be meticulous and thoughtful. Doctors attend to the details.

And doctors can make mistakes, especially when it comes to dictating reports.

I get it. Doctors have to see patients and attend conferences and do consultations and have to deal with insurance and therapists and have a lot on their plates. They hire staff do streamline their offices and deal with the minutiae that comes with their jobs. Dictating reports is far down their list of things to do, and often doctors want to get through the reports as quickly as possible so they rush, speaking faster than the speed of sound, speaking while they're eating or chatting with colleagues and staff and friends, speaking with colds and out in the wind and rain or while sitting at a light in traffic, speaking while the television is on or their child is practicing scales on the piano, trombone, or other musical instrument. Doctors speak when they can, often between patients, without thinking of what that will cost them in time and effort down the road.

The fact is that doctors forget the most important person: the medical transcriptionists who decipher what doctors dictate and get it right every single time because ultimately it is the patients who will suffer if a lab value, procedure, dosage, or part of the body is wrong.

Doctors do not realize--or maybe they have forgotten or never knew--what level of skills transcriptionists possess and use every day.

A medical transcriptionist must be skilled at typing/data processing first and foremost, but that is the least of her skills. A medical transcriptionist (MT or MLS for medical language specialist) must also be up to date on grammar, punctuation, spelling, and the use of computers since most dictation is done over the Internet; however, these are basic skills. We are not talking about high school grammar, but the grammar, punctuation, spelling, and style guides for medical transcription, which is a very different ball game from what is learned in high school or even college. Just as journalism and business use different style guides, medical transcription requires its own style guide.  But there are more skills involved in the MT's arsenal.

An MT must also be proficient in normal lab values for every test run by a doctor and hospitals so that when a normal lab value for a complete blood count (CBC) or liver function test (LFT) is wrong, the MT catches it, flags it, and returns it to the doctor or hospital for verification.

Medical terminology is another useful tool in the MTs arsenal and central to the job she does. It's not enough to know how to spell tibia and olecranon bursa and every other Latin-based word used in the medical profession, but the MT must also know where the tibia and olecranon bursa are and why on a radiology report that a CT of the pelvis would not include either the tibia or the olecranon bursa because one is a bone of the leg and the other is the membrane in the elbow. In addition to medical terminology obviously anatomy is another tool necessary for an MT to do the job correctly.  How many people on the street can tell the difference between the capitellum and the cerebellum and where both are located?

An MT must also be proficient in the tools used for operations and why a Bookwalter retractor would not be used in setting an humerus fracture. The tools used in major and minor surgeries are specific to each surgery. An Allis or Kocher can be used during the same operation, but each serves a different function just as the lancet and a scalpel. The equipment and tools used changes frequently and the MT must be proficient in knowing the latest techniques and tools, from robot-controlled surgery to an appendectomy, neither of which is simple.

Knowing which medications are used and in what quantities is crucial to patient safety and avoiding lawsuits as is whether or not a patient is allergic to a medication or group of medications, like sulfas and penicillins. Although it seems as though an MT would not be aware of a patient's history, even when it is often part of the report a doctor dictates, little things like a cephalosporin or statin allergy where a doctor dictates in the same report that the patient is prescribed Fortaz and Lipitor, both of which will kill or cause serious problems because one is a cephalosporin and the other a statin. The MT must also be familiar with the dosages of medications prescribed so that errors will not end up causing a mistake that can lead to a malpractice lawsuit if it is not caught, often by the MT, and reported to the doctor.

From brain surgeries as delicate as an aneurysm coiling to setting a break from a fall off the monkey bars at school, the MT types it all -- and knows a lot more than they are given credit for. Oncology drugs and treatments, the waveforms and epileptiform discharges on an EEG, the variable rates and states of the heart on EKG, skin grafting, the delicate bones in the hand, the difference between a floater and a posterior vitreal detachment, sizes of drains, and every single discipline and specialty in the medical service, as well as the the diagnoses and treatments for everything from a flu bug to schizophrenia are part of the knowledge and abilities of every MT.  With all that knowledge and expertise, every MT relies on the doctor to do his job and dictate clear and easily understood reports so that time is not lost and patient care compromised in the meantime.

The biggest hurdle that the MT must manage is the doctor who is too busy or tries to fit in dictating reports whenever he can. Is it because the doctor doesn't care about the patient or is it because he does not consider dictating the report as important as treating the patient or attending a morbidity and mortality conference? Whatever the reason, doctors are most often the part of the medical machinery that causes the most problems when it comes to accurately documenting patient care. I think it is because the doctor is not aware of how much time and effort costs when the report ends up back in the doctor's hands with blanks and questions about dosages, allergies, and discrepancies in the report he dashed off hours or days ago. The doctor has forgotten that there is a bottom line and a price to pay for hurrying through dictations and ultimately it is the patient who will pay.

When a doctor speaks too fast, mumbles and fumbles through a dictation, doesn't speak clearly, speaks when there is too much noise in the background, or doesn't read the chart before dictating, the doctor creates problems, not just with the timely processing of the dictation, but also the documentation of the patient's treatment. When English is the doctor's second language, that doctor has the added responsibility of speaking as clearly as possible, spelling out words difficult to pronounce correctly.

The MT listens to the report, typing everything the doctor says because each report is a legal document, correcting minor errors like grammar, punctuation, and style, but the report must be accurate as well as correctly typed and processed. Misdiagnoses, wrong dosages and medications, incorrect materials and equipment, and wrong lab values must be flagged and sent back to the doctor to correct before each error is finally documented as proof of the doctor's treatment and care of the patient. All of this information is admissible in a court of law if the doctor is ever sued for malpractice. It is more important to the patient who can be harmed by incorrect dosages and types of medication, treatment, and errors in lab values, or sites of surgery. Most, if not all, of these errors are preventable by the doctor speaking clearly and at a natural conversational rate of speed so that the report does not have to go through the MT, 2 or more quality control specialists, the hospital, and finally back to the doctor who rushed off the dictation in a spare moment and now must read the report and correct the errors, matching it against the patient's chart for a second, and often third time.

Not only has he wasted the time dictating the report, but the report has wasted the time of everyone that had to handle the information to try to tease out what the doctor said or meant to say, sending it back up the line to the doctor to correct before the report becomes a part of the patient's chart and cast in legal stone. Had the doctor taken the time to dictate the report clearly and accurately the first time, the report would not end up back on the doctor's desk to be corrected.

Every time an MT complains about a doctor who chronically wastes her or his time, it is not the MT whining or complaining for the sake of complaining, but a message to the doctor that patient care is at stake and valuable time has been lost by everyone that had to listen to the original dictation numerous times to puzzle out what the doctor meant, doing everything possible so that the report does not end up back on the doctor's desk to be corrected and the blanks filled in. Each time that happens, money and time are lost, but more importantly patient care and safety are lost or left in a holding pattern in limbo, which may also hold up care and proper treatment when the consulting doctor or therapist or surgeon has to wait for those blanks to be filled in and the errors corrected.

The bottom line is that patient care and safety are at stake every time the doctor rushes through a dictation because dictating that report is low on his list of priorities as he rushes to get it done. Rushing leads to errors and that leads to compromising the patient's care and safety -- and that often leads to malpractice lawsuits for the hospital and the doctor.

I ask you, doctor, is it worth it?

My grandmother taught me that doing a thing right the first time means I didn't make mistakes I would have to correct -- and answer for -- later. I learned that lesson early. It is a lesson we all must learn.

Most mistakes on hospital reports are not a result of mistakes made by Medical Transcriptionists, but are made by doctors who do not take the time to dictate slowly and clearly enough. Mispronounced words make it difficult for the MTs to do their jobs with the precision and skill of which they are able. An MT can only do so much. In the end, it always comes back to the doctor. The doctor ultimately has the power to make the MT's job easier or make more work for him/herself and avoid compromising the patient's care and safety.

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