Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial

I appreciated reading this report by Gidwani et al.[1] describing the results of a randomized trial of scribe use in the primary care setting. The study design involved 4 physicians and 2 scribes in one clinic who were randomized to 1 week on and 1 week off charting with a scribe for 12 months. The participating physicians were part-time, with (4) four-hour clinic sessions per week where data were collected for the study, and were relatively recently out of training (mean 6 years of experience). Physician satisfaction was assessed with a questionnaire after each clinic session and patient satisfaction assessed after each visit. Charting efficiency was assessed based upon whether chart closure occurred within 48 hours. Physician satisfaction regarding the clinic session, face time with patients, and perceptions about documentation was improved, patient satisfaction was high with or without a scribe present, and chart closure within 48 hours was only slightly improved with the presence of a scribe.

While these results are encouraging, I wonder to what degree these results can be extrapolated to real-world busy primary care clinics. Even with a group of 4 physicians who were relatively recently out of training (and possibly familiar with using electronic medical records(EMRs)), worked with one of two scribes for the entire study, and had less than half of a full week of clinic observed, the percent of chart closure times within 48 hours was only slightly improved (although statistically significant) and still low(28.5% vs 32.6% without and with a scribe, respectively). With a larger number of visits per week, it is not clear that the presence of a scribe would make a significant difference and the cost of having a scribe may not justify this small level of improvement in this metric.

While the authors suggest that utilizing scribes during a clinic session may help mitigate physician dissatisfaction with the EMR, it is unclear to what degree scribes can contribute to improving physician work-life overall, as chart documentation is just one part of a practicing physician's interaction with the EMR. As primary care delivery moves to models focused on managing populations of patients, additional tasks unrelated to the actual visit time will be a greater expectation of the work of a primary care team. This work, often part of the in-box messages which can be time consuming,[2] includes answering patient phone calls or patient communication through the EMR, refill requests, completing paperwork, and participating in further outreach to patients in our newer population-based models of care. An unlicensed scribe can only contribute to a small part of that overall workload. The authors state that "Spending less time on documentation frees up the physician to pursue direct clinical care and care coordination, thus enhancing joy of practice and preventing burnout." It is not clear how much less time was spent documenting and physicians were still required to sign off on charts. While greater face time with patients in team-based models utilizing scribes, as we have also previously reported,[3] may foster improved physician-patient relationships and thereby improve work satisfaction, a non-licensed medical scribe model, as reported in this study, cannot be helpful with the large burden of after-visit work. We have studied a model at our institution that involves medical assistants or licensed practical nurses taking on scribing as part of their role,[4] who then also have the ability to develop relationships with patients and can assist with other non-scribing tasks. Innovative models that involve other clinical team members who can help physicians care for our patients through developing long-term relationships with patients and teams have the potential to affect both patient outcomes as well as physician satisfaction. The results of this study suggest that unlicensed medical scribes may be a promising part of the solution and I agree with the authors that scribes may "serve an important function in a multidisciplinary health care team."

Anita D. Misra-Hebert MD, MPH
Department of Internal Medicine and Center for Value-Based Care Research, Cleveland Clinic

References
1. Gidwani R, Nguyen C, Kofoed A, et al. Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial. Ann Fam Med. 2017;15(5):427-433. doi:10.1370/afm.2122.
2. Murphy DR, Meyer AD, Russo E, Sittig DF, Wei L, Singh H. THe burden of inbox notifications in commercial electronic health records. JAMA Intern Med. March 2016. doi:10.1001/jamainternmed.2016.0209.
3. Misra-Hebert AD, Rabovsky A, Yan C, Hu B, Rothberg MB. A Team-Based Model of Primary Care Delivery and Physician-Patient Interaction. Am J Med. April 2015. doi:10.1016/j.amjmed.2015.03.035.
4. Yan C, Rose S, Rothberg MB, Mercer MB, Goodman K, Misra-Hebert AD. Physician, Scribe, and Patient Perspectives on Clinical Scribes in Primary Care. J Gen Intern Med. 2016;31(9):990-995. doi:10.1007/s11606-016-3719-x.

Competing interests: Dr. Misra-Hebert is supported by an Agency for Healthcare Research and Quality grant K08HS024128.