Should fellows be dictating notes?



Did you ever think you would be thinking about this?  I rememebr as a medical student, seeing older physicians, with at least gray but usually white hair, dictating notes.  I thought to yourself, is he or she that lazy? 


Fast for a few years, and the thought of writing another history and physical, from scratch, without any Drag and drop features from the electronic medical record system, sure seems like a daunting task.  And it is for good reason.

Why? Because the reality is you are not writing a note for yourself.  You are writing it for

A insurance companies

B lawyers


C colleagues

D institution

If you are writing a note just for yourself, you would not even write a formal note.  You would jot down bullet points, note other salient features and call it a day.  But like everything else in life, nothing lives in a vacuum. 

Getting back to the main point…Should you dictate ? 

The answer is yes.  You should dictate.  At the least, you should learn how to dictate and become more efficient.  There may be some apprehension, for variety of reasons.  Perhaps it does not come naturally to you, because you have likely been going from thought to keyboard and has become second nature like writing.  Perhaps you are self-conscious speaking into a microphone around other people or not.  Perhaps you think it is a sign of laziness.

All of those reasons are rubbish.

Let us review the first one:

You are not used to it.  Of course you are not used to it. Jeff Bezis wasn’tbused to beinf a billionaire, but he accustomed. You just adapt.  The reality is, medicine is moving into a volume based model.  There are less and less solo practitioners, and they are less and less and hand-written chicken scratch notes.  You nowshare notes to physicians working in multispecialty groups as part of a larger institutions, who are constantly sharing notes.  Other people expect to read your notes and expect a fair amount of detail if you want to minimize criticism or even being reprimanded.  And if you are seeing upwards of 20-25 patients a day, or not in the 90th percentile for typing, then your only solutions are significant copy pasting, or spending an extra 5 to 10 hours/week typing.  Think about that for a minute 5-10 extra hours per week, translates to 20 to 40 hours/month.  That is almost an extra 2 to 5 days of work.  That is absurd.

The second reason is that people can get self-conscious speaking into a microphone around other people who are typing.  That is understandable, nobody wants to stand out. in this scenario, I would recommend moving to another private location, and dictating.  There are numerous tricks you can use, if you are new to this.  When I interview the patient, I jot down bullet points, generally between at least 10-20 salient features from the patient’s history,.  And then I glance at it for about 20 to 30 seconds and plot out my dictation.  And then I just start.  You will be surprised how much more beefy and bulky you can make a history and physical given deficiency of dictation.  While the speed at which she dictate, mumble, accent, may play a role, you will soon learned to adapt your style to the microphone, and save yourself a tremendous amount of time at the end of the day.  While some people criticize the editing portion, this is still significantly faster compared to someone who is a slow taper.

Lastly, there is a private issue.  Some people think it is below them to dictate.  They think it may be a sign of laziness or aging or who knows what else.  The reality is, you are asked to do a service, which is right a very particular type of note, bound by other people’s rules.  As I mentioned above, insurance companies, institutional standards, malpractice issues, as well as review for other colleagues.  Now thinking of these variables, what does this have to do with necessarily providing better patient care.  Nothing really.  A note will not change how conscientious of the physician you are.  Something 0 very much out of her control.  The healthcare matrix is very complex and evolving, and physicians are taken along for the right.  You need to think about your mental wellbeing, and part of that involves spending less and less time on unnecessary tasks, such as insufficiently putting together notes.

In conclusion, if you have never dictated, or not comfortable with it, you should get used to it.  If your institution does not offer a subscription, go purchase one.   Spent some time getting used to it.  They will have strong customer service programs, which can help physicians pick up tricks to really improve the process.  If you really do not want to do the editing yourself, you can pay for a transcription service, and they will upload the note to you.  Keep in mind that there is a lag time, and editing in real-time becomes a problem.

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