Pulse of Longwood takes you inside one of the nation’s largest hubs of hospitals and biomedical research.
As the doctor rushed through the emergency room, Warren Lam stuck beside her, typing what she said for eight hours for minimal pay. In exchange, he got a rare, behind-the-curtain view of a job he aims to have one day.
Lam, a 22-year-old aspiring doctor, is part of the fast-growing industry of medical scribes working in hospitals and clinics across the country. These scribes, often premed college students, help doctors with a dreaded task — checking boxes and typing words into electronic health records.
After the federal government spurred hospitals to adopt electronic health records seven years ago, scribes have proliferated in emergency rooms and outpatient settings. The number of medical scribes in the country has grown from about 7,000 in 2014 to nearly 17,000 today, according to the American College of Medical Scribe Specialists.
Lam works nearly 40 hours a week in the emergency room at Beth Israel Deaconess Medical Center. His employer, PhysAssist Scribes, supplies scribes to emergency rooms in 36 states. One recent day, he followed Dr. Laura Burke as she treated 25 patients for a wide range of complaints, including a bad rash, a stroke, a broken leg, psychiatric problems, and a new cancer diagnosis.
Dressed in all-black, Lam was Burke’s silent sidekick. Beyond a brief mention — “I’m Dr. Burke, one of the emergency doctors, and Warren is one of the medical scribes” — he went largely unnoticed. As a scribe, he’s not supposed to interact with patients; his job is to observe.
Lam typed into an HP laptop computer continuously, even while walking down the hallway. As he followed the doctor, he found creative positions to type from — teetering the laptop atop a chair, leaning on a sink, or resting a foot on a hospital bed to create a bended knee.
Lam, who grew up in Milton, Mass., and graduated from Vanderbilt University, is applying to medical school. Burke, his guide to the medical world, is a 35-year-old attending, or supervising doctor, in the emergency department.
Burke walked briskly among the emergency department’s 50 rooms and overflow beds in the hallways, following up with patients who had been seen by the two doctors-in-training she was overseeing.
At 11:50 a.m., Burke and Lam rushed to a “trigger” call — an alert that summons a team of nurses and doctors to assess a severe case. Maria Angélica Aguilera González, 72, was wheeled into Room 3. She had just seen her personal doctor, who was concerned that bleeding from hemorrhoids was causing her blood pressure to drop. Lam slipped behind the curtain, into the room, as Burke led an examination.
“What were you most worried about when you went to see your doctor today?” Burke asked.
Burke later translated a question the patient wasn’t understanding — “Ever have thoughts of harming yourself?” — into Spanish.
“No, no! I’m very happy,” replied González, who did seem to be brimming with joy, despite having kidney disease.
Lam translated the dialogue into an entry in the hospital’s electronic health record, which Burke would later review, correct if necessary, add to, and sign off on. He went everywhere she did — even donning a mask and entering a room with an immunosuppressed patient with a high heart rate. After the team left the room, Lam was so focused that he kept typing with his mask on for several minutes.
In addition to checking boxes, Lam typed narratives like this one: “21 Y/o M presents to ED with left hand burn after someone spilled coffee onto his left hand at work at the coffee shop at 1030 today. He applied lidocaine cream on his hand but still has pain. He denies any swelling, blisters, and is able to move all of his fingers.”
By 2 p.m., the waiting room was backed up with 10 patients, and Burke’s team had to step up the pace. She barely took a break all day, except to pump breast milk for her 10-month-old son. Lam said he usually keeps typing during her pumping breaks: “It’s still kind of hard to keep up.”
Medical scribes are largely unregulated; no license is required. At PhysAssist, scribes get 40 hours of training, in which they learn medical vocabulary, privacy law, and how to write charts, according to spokesman Cameron Cushman. Then they do eight supervised shifts before working on their own.
Pay ranges from minimum wage to $12 per hour, depending on the state and hospital, Cushman said. (Massachusetts’ minimum wage is $10.)
“We’re targeting people who aren’t in it for the money,” he said. The organization typically hires college juniors or seniors who aim to go into a medical profession.
Turnover among scribes is “very, very high,” Cushman conceded. But it’s meant to be an introduction to medicine, not a career, he said. “It’s the best clinical hours and experience you can get.”
Though he’s been working just a few months, Lam is now the most senior scribe in the emergency department. He said he has learned a lot about medicine, and about what being a doctor is like.
“You really learn to appreciate how much doctors work,” he said. “They are just constantly working throughout the shift. … It’s a lot harder than what I would’ve expected.”
Not all doctors at Beth Israel Deaconess have scribes. Physicians have to take money from their paychecks to pay for the scribe’s wages, plus overhead to the company. Burke said she decided to get a scribe because she found that in the fast-paced ED, “it was really hard to get my notes done in real time.” She still has to check and amend the scribe’s work, but it cuts her charting workload in half.
“I just don’t like being at a computer when I’m in the room with patients,” she added — a complaint that is common among doctors. “I’d rather be talking with patients.”
None of the other Longwood Medical Area facilities reported using scribes, except for Brigham and Women’s Hospital, which is trying them out in its emergency department, several outpatient specialties, and a satellite urgent care clinic, according to spokeswoman Lori Schroth. Beth Israel Deaconess started using scribes in the emergency room in 2011, and now uses them in several other settings.
Burke said it takes time for new scribes to learn medical jargon and figure out which details are important to write down. But she prefers scribes to dictation machines, which bring their own problems, such as this blooper: When a doctor said that shingles is caused by a virus that “lies dormant in your nerves,” the machine changed it to “lies tormenting your nurse.”
A review of a handful of studies found scribes can improve a doctor’s productivity and satisfaction, though not much research has been done. Burke said scribes don’t enable her to see more patients, but they do free up time for more enjoyable activities, such as playing with her two sons.
“It generally improves my happiness at work,” she added. “I feel like I can just think about the patients, and not just think about the charting part of it.”