Autonomic Angst Conjured By The Word-Which-Must-Not-Be-Spoken to Physicians

If while speaking to a group of physicians you use the word “provider” before you come to your important point, you will never get your point across.  In fact, you may not even get another sentence in, such is the autonomic angst conjured by the word-which-must-not-be-spoken

Most physicians resent being called the word-which-must-not-be-spoken, and some are instantly enraged by it.  Protect your valuables should you let it slip out of your mouth.  It is felt by physicians to be demeaning and disrespectful.  There are many reasons given for this, but I think the root cause is that the word-which-must-not-be-spoken is intertwined with bureaucratic red tape that has increasingly constrained the practice of medicine, especially over the past decade.  For example, the CMS Meaningful Use, PQRS and MIPS payment programs are all written for “eligible providers”.   Literally thousands of pages of rules, regulations and policies that impact the day-to-day activities of those who are said to be a word-which-must-not-be-spoken.   

Who wouldn’t resent such a word?

This happened because the word-which-must-not-be-spoken was adopted by policy writers for the rules and regulations associated with Medicare and Medicaid, as well for private insurance payors, to lump together all of the clinicians they pay for providing health care services to their clients.  To make it easier to write such regulations and policies, a single word was chosen to describe all the people that this word intentionally lumps together--physicians (M.D.s and D.O.s), nurse practitioners, physician assistants, podiatrists, chiropractors, dentists, anesthesiology assistants, audiologists, certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, clinical social workers, occupational/physical therapists, psychologists, registered dieticians and speech language pathologists to name a few. 

It sounds reasonable to lump all those people in with one word when writing policy rather than writing the whole list every time, doesn’t it?  But the word-which-must-not-be-spoken has unfortunately spilled out of regulatory-speak into common vernacular.  Personally, I can verify that after reading a 400-page CMS rule where the word-which-must-not-be-spoken is used over a thousand times,  it gets imprinted on the brain and difficult to avoid using for several weeks afterward.  So now PCPs are not primary care physicians anymore, but instead are called primary care words-which-must-not-be-spoken

So, one may ask, why did the policy writers not call us clinicians instead?  That would be more palatable. 

Well, the issue is that CMS and private payors also pay “entities” such as acute care hospitals, long-term health care facilities, physician practices and other clinical facilities and practices.  All of these entities are also considered to be “providers”, but they are not clinicians. 

Since entities do not have independent thoughts or feelings, they are not offended by the word-which-must-not-be-spoken, so you can call them providers without fear for your valuables.  In my opinion, it would have been better for policy writers to differentiate clinicians (people providers) from entities (facility providers), but that boat left the dock more than a decade ago.

I admit to being rankled for many years by the word-which-must-not-be-spoken, but I've gotten over it.  If one ignores the connotation of the word due to its overuse in bureaucratic red tape, it is really not such a bad word.   In fact, look it up in the dictionary, and you will see it is actually a word one should be proud to be called. 

Although I understand the autonomic angst conjured by the word-which-must-not-to-be-spoken, as it has been thoroughly butchered by government policy writers, at the end of the day call me a "provider of quality healthcare" and I'll go home happy.

Or just call me "Matt".

Matt Murray, M.D.

Provider of Quality Healthcare


Does use of a Scribe in the Emergency Department Increase Productivity and Improve Patient Flow... Yes, But...

Does use of a scribe to document in an electronic health record (EHR) increase an ER physician’s productivity?  Do scribes improve ED physician’s satisfaction with their profession?  Do scribes help improve ED patient flow? Well, overall yes, scribes improve productivity, but not necessarily for all ED physicians.

I am a pediatric ER physician and my pediatric emergency department (ED) has a scribe program.  Use of scribes was "free" until 3 years ago when our organization decided to stop paying for scribes.  A compromise was made, though, with ED physicians--we could individually decide to continue using scribes, but would have to pay half the cost.  All but 2 of 28 ER physicians decided to continue using scribes.  The cost is essentially covered by seeing a couple additional patients each shift.  Clearly the majority of us feel scribes improve wRVU production by more than that.  And since ED physician productivity is one of the main factors within the ED patient flow diagram, increased productivity correlates with fewer bottlenecks and overall improved ED patient flow. One colleague told me he sees a 20% decrease in productivity when he does not use a scribe, but the degree of impact varies from physician to physician in our group.  Part of the increased productivity has to do with tasks a scribe can do other than EHR scribing, like fetching this or that.  And in some cases, it looks like scribes help physicians cherry-pick lucrative patient cases---don't get me started on that one (I finally figured out why I never got to see the known appy patients that got transferred in).

All of our most highly productive ER physicians use scribes.  In addition to being naturally gifted "fast" physicians, they spend less time on documentation during their shift.  Most of their notes are in draft form at the end of the day.  Some will spend 45-60+ minutes editing and signing notes after their last patient, but most will go home and complete the notes 1-2 days later.  I think scribes are particularly valuable to those faster-types of physicians, both for productivity and for physician satisfaction.  Scribes allow them to maintain a fast pace with less work to do after their shift to complete charts.  

I am one of the two exceptions who chose not to pay for a scribe.  Both of us take a methodical approach to seeing patients, hence neither of us are in the high productivity range, but neither of us saw our productivity drop.  In fact, I eventually found that I could see more patients without a scribe.  Most of my notes are completed and signed when the patient is discharged, and typically the rest of my notes are completed within 30 minutes after seeing my last patient.   My method of working requires me to spend a lot more time documenting during my shift as compared to "fast" physicians, unless its crazy busy when documentation simply has to go out the window for the sake of getting patients seen and properly cared for. 

Why would some physicians like myself be faster without a scribe?  This would be a great subject to study.  In my individual case I feel it has to do with how my mind processes information and my method of working.    

First, I am 59 years-old, and the framework for my thought processing in previous decades was built around formulating a plan as I wrote out my ED note on paper.  When EHR and scribes came along, I found it difficult to process information and formulate a plan while verbalizing information to a scribe, so I ended up using a small notepad to write brief notes to help me "think" as I spoke to the scribe. I apparently need to see the words to help me plan. With voice recognition I can see my words going onto the screen, similar to when I saw them going on paper, and I thus find myself better able to process information and formulate a plan simultaneously.  Second, although I'm older and not as efficient using a keyboard as my younger colleagues, I'm tech savvy.  After eliminating use of scribes I found ways to leverage voice recognition and certain personalization tools in our Epic EHR.  Using our voice-recognition tool I created HPIs, MDMs, critical care templates and discharge instructions with built-in [macros].  I also created voice commands to dictate frequently used smartphrases that can be built in Epic.  Whenever I found my hands leaving the mouse and dictation device to reach for the keyboard, I would make note of that and later on think about ways to eliminate the need for a keyboard in that particular situation using voice recognition or personalization tools within the Epic EHR.  For frequent point-and-click actions (i.e. Save, Enter, Order, Open My Note....) I programmed buttons on the dictation device which significantly reduced mouse clicks.  Thus, I now spend most of my day with one hand on the dictation device and the other on the mouse, and happily see more patients without a scribe.

So in our group nearly all of the ED physicians subjectively feel scribes improve their productivity and, as a result, improve ED patient flow.  Even when the organization reduced reimbursement for the scribe service to 50%, nearly all chose to pay for their scribe service.  At least one ED physician sees a 20% decrease in productivity without a scribe, but the degree of impact varies from physician to physician..  And finally, the two ED physicians who decided not to pay for a scribe were able to maintain, or even increase, their productivity.