At the heart of the accuracy and accountability issue is the owner of the record, the physician. And if the owner doesn’t care about accuracy (or style, format, grammar and punctuation), should the transcriptionist?
For me, it comes down to personal integrity.
Does a doctor know that a short arm cast is not the same thing as a short-arm cast? Explain this common error to anyone who is a grammarian and they immediately see why short-arm cast isn’t correct, but don’t bother explaining it to the administrator of a clinic or a doctor – most of them don’t know and won’t care. It’s the same three words the doctor dictated and that’s all that matters to them. Nobody will be injured or die as a result of this error. In my book, however, the inclusion of that one seemingly insignificant hyphen is a critical error because it completely changes the intended meaning of the medical term. Getting it right, correcting it in every report that comes across the QA editing desk, is only a matter of personal integrity because nobody else seems to care that it’s wrong.
To me, integrity means you do what’s right even if nobody else does and/or nobody else cares or nobody is ever going to see your work. Most people get a great deal of satisfaction and gratification from a job that’s done well.
There are, of course, bigger issues in medical transcription, and those are the big, whopping errors. I’m talking about transcription so wrong it makes absolutely no sense. I’m talking about anatomical impossibilities. I’m talking about transcription that isn’t even close to what was dictated.
And those are only the examples of errors where the dictation is clear. Let’s face the real truth: doctors are some of the worst dictators I’ve ever had to listen to, and I’ve listened to a lot of dictators from a wide variety of professions. When I was taking medical terminology classes, it slowly started to dawn on me that knowing the terminology was only part of the difficulty in doing medical transcription. I took the class because I was doing a lot of transcription for workers’ compensation professionals and got tired of looking up the spelling. I asked the instructor, who also had a medical transcription service, if I could listen to actual dictation, and I was appalled at how awful it was. My experience (up to that point) was with dictators who spoke clearly and thoughtfully and took care to enunciate. It didn’t prepare me for what I would experience in medical transcription. I can make allowances for ESL doctors as long as the way they dictate indicates that they have some insight into the fact that they are difficult to understand. I might not like having to listen to a doctor with a heavy accent, but I accept it as part of living in a melting pot. What I don’t understand – and won’t make allowance for – are dictators who act as though they have no regard for the person who is going to have to make sense of what they’re saying. Every transcriptionist out there could tell stories so I’m not going to, but you all know what I’m talking about. What gets my blood boiling is the knowledge that if they stood up in front of a room of colleagues to describe a surgical procedure, the doctors could and would speak clearly, but somehow they excuse themselves from that courtesy when the person listening is faceless and not a colleague (read: someone they respect). Frankly, I think transcriptionists all over the world have spent more time trying to decode this dictation than the dictators deserve.
Back to transcription errors…
Have you ever looked at some of the documents doctors sign off on and wonder what else they’re sloppy about? To me, inaccurate medical records reflect not only a lack of personal integrity on the part of the doctor, but a lack of work ethic. It’s like making an announcement that you only do a good job because someone is standing over you making you do a good job, or because you fear the consequences of not doing a good job; absent that oversight, you’d be willing to do whatever is easiest and/or cheapest and call it good. And yet, I know many excellent doctors who accept substandard transcription. Is it because they’ve come to believe nobody can deliver better? (Sadly, for many of them, yes.) Some of it can be attributed to caring, but being worn down by trying to get a better product and not finding it. Some of it can be attributed to an unwillingness to pay for something better.
I’ve heard all kinds of excuses over the years, with time constraints predominating, but in reality what it comes down to is money. Pretty much every professional who generates extensive documentation gets paid for the time they spend on it or can bill for the time of an employee who gets paid to do it, regardless of whether it’s produced by dictating or copy typing or that professional sitting at a computer. Lawyers get paid not only for the time they spend dictating, but also for the cost of the transcription. With some exceptions, doctors don’t get paid anything extra to generate medical records documentation and therefore they see it as a necessary (and expensive) evil.
Let’s go to my favorite analogy: food. We all have to eat, just like doctors have to document. If you are only willing to pay for hamburger, even if you can afford something better, don’t complain that all you have is hamburger. If you eat hamburger because you like expensive wine and you aren’t willing to give it up or cut back to eat something other than hamburger, don’t complain that all you have is hamburger. If you truly and honestly can only afford hamburger, then you’re just going to have to make the best of it and find the best hamburger you can afford. In all cases, it’s very unlikely that your hamburger is ever going to transform itself into filet mignon, so don’t get offended with the butcher when you pay for hamburger and get hamburger. You can take that hamburger home and pound it as much as you want and cook it any way you want, and it’s still never going to be anything more than hamburger so don’t complain that it’s hamburger and don’t take it back to the butcher and raise a stink because it’s still hamburger. And don’t tell me you didn’t know you were buying hamburger when you’re paying less than half for hamburger than you would pay for top sirloin and only a third of what you’d pay for filet. If you buy filet mignon and get hamburger, by all means – raise a stink. And if that butcher keeps giving you hamburger when you pay for filet, you’re going to find another butcher. If every butcher you find gives you hamburger instead of filet, eventually you’re going to conclude that only hamburger is available and you’re going to stop paying for filet. Whatever your reason for buying and eating hamburger, you will probably continue to do so as long as there is no compelling reason to buy and eat something better. (This whole discussion is probably another part of this series, but it has to be said.)
What is the point of making a record if the record doesn’t accurately reflect the circumstances and the event?
One purpose (some people would say the only purpose) of a medical record is its use as a reimbursement vehicle. As long as the record contains sufficient information to get paid, that’s all that matters. Again, the people receiving these documents for payment don’t know and don’t care whether anything else is correct; they’re looking for specific information and as long as they find it, the rest of the report could be complete gibberish.
Last year, I had cataract extraction and IOL implantation. Each eye is done separately, two weeks apart. When I saw the doctor, I filled out a medical history form. A few days before the surgery, I got a phone call from the surgery center and they took my relevant medical history over the phone. On the day of the first surgery, they took it again in the surgery – three times. Two weeks later, they do the exact same thing with the phone call and the verbal history in the surgery center. They would have done all that even if I had brought my own typewritten history to both places, both times. Why? To make sure the information is accurate and consistent. But, I say, it’s all there in the record! People make mistakes – in dictation, in reading, in writing. The purpose of the multiple checks is to make sure the information is accurate. It might be the only information that’s accurate – the dictated report of the surgery might be full of errors – but prior to surgery, they are by damn going to know whether you have medical issues, take any medications, have any allergies, or have a lifestyle that might negatively impact your health. Once you’ve successfully survived your surgery and they’ve been paid, the record becomes irrelevant (apparently). And honestly, even I don’t care what the operative report says unless there’s a negative outcome. All I did was add “bilateral cataract extraction and IOL implantation” to my own personal medical history, which is more than the average person does.
So… what is the sound of one hand clapping? If a tree falls in the forest and there’s nobody to hear, does it make noise?
Unless and until a sufficient number of negative events occur as a result of documentation and/or transcription errors, reports filled with errors will continue to be accepted.
NEXT: What does all this mean for transcription now and in the future?