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Medical Scribe: Part 1

November 16th, 2011  |  Published in Pre-Med Tips

During a general chemistry tutoring session, I first heard about being  a medical scribe. I thought it was the coolest thing ever; you see cool stuff, you get paid ($$!), and scribing looks good on your resume. I applied, went to an information session, had an interview, and then was swiftly rejected.

So I applied again; two years later, the process was even more tedious. After completing a quiz about the responsibilities of a scribe, being tested on my current knowledge of medical terminology, and surviving a typing test and an interview, I landed the job. Entirely thrilled, yet nervous that I was going to be taking on too much, I began the flurry of orientations and training sessions required by my employer.

The first day on the job I was extremely nervous, especially since I am late everywhere, and my first shift began at 6:00 am. Of course, something happened when I was making my breakfast egg, and I was late. Panicked, and barely able to see through my foggy window (dew point reached at 5:30 am,) I drove 15-20 mph over the speed limit and arrived at the requisite 15 minutes prior to my shift, as my employer requires for all trainees.

The trainer? Not there yet. So I awkwardly perched on a chair and sat next to the previous shift’s scribe, anxious that I hadn’t clocked-in yet, not knowing which computer I could use. Trainer arrived, and the shift began. The electronic medical record system (EMR) was confusing; it isn’t intuitive and the patient visits are very short relative to the time needed to complete the chart. Over time though, I’ve finally become comfortable with the EMR and I can somewhat relax in the patient’s room, ears attune to their small whispers that describe their symptoms.

My employer continually reminded us that as medical scribes, we are part of the “patient care team,” indirectly caring for the patient by recording their information. During my first few shifts, whether because of my novice understanding of the EMR or my feeling of being cumbersome to my supervising physician, I felt that I stuck out awkwardly in the room. All I could think is that the patient was thinking “Who is this crazy person in the room sitting on the chair the doctor was going to sit in and typing on a laptop next to a cup of my pee?” (They always leave the urine sample on the only available flat surface in the room that has space for my laptop.)

Just as they say when you are trying to land a date you need confidence. After what felt like billions of introductory training shifts where I would inevitably forget something such as how to discharge a patient, I was in control. I zipped around behind the doctor like a shadow, gracefully swept past the possibly-MRSA-laced privacy curtain, and settled onto a counter or balanced the laptop on my knee like a pro. The confidence (or maybe the scrubs-and-laptop combo) gives me authority in the room, not greater authority than the doctor, of course, but the patients recognize that I’m the person recording their information. “Make sure the doctor knows this,” the patient’s family will whisper to me, worried to let their loved one, the patient, know the truth about their failing health. Sometimes they glance at me when they are talking, and that makes me realize how critical my work is.

But the true golden moment of my greenhorn career occurred a few weeks ago. A patient came to the hospital, distressed to be here for treatment. I was forcing myself to maintain my usual stoic face as I recorded the patient history. I listened attentively, watching the doctor shift to the other side of the table and anticipating he would begin the physical exam at any moment. Perhaps because I looked genuinely concerned, perhaps because I was making eye contact with her, or perhaps because I was the only other woman in the room, she smiled at me. I smiled back, hoping to express my sympathy of her condition and to provide a small comfort in a place in which she felt uncomfortable. At the end of the exam, we left the room, I smiled at the patient one last time, and she said to me “Thank you,” with a grateful smile.

Previously, I never thought that my scribing would serve any benefit to anyone except the physician, who has less of a headache and is able to provide better care to his/her patients. But evidently, sometimes just being in the room is all that someone needs.