A few nights ago I had a report, a patient's first visit with a diabetic education counselor. These counselors, they're the people who tell you to take the insulin like this, watch your carbs, watch your fats, blah blah blah.
The patient's age? North of 90.
You know what education I have to give to someone over 90? "Try not to get hit by a bus. Otherwise, keep up the good work."
There are days you couldn't pay me enough to do my job. This is one of them.
I am past ready for my so-called industry to obsolete itself. Voice recognition? Bring it. Automated charting? Dear sweet heaven above, PLEASE. The faster these little buttmunches have to give themselves carpal tunnel instead of foisting it onto me, the better.
Oh!--Please note the disclaimer. Because again, I'm not talking about the millions of health care providers out there who are just trying to do their jobs. I'm talking about a certain provider at a certain ultra-snooty facility who needs to quit thinking he can dictate chart notes at me through a mouth full of Quaaludes. I don't care if the dude does regularly arthroscope all manner of sports celebrities, he's still a total fucking hump and I'd like to stab him in the umbilicus with a knife edged in his own teeth, which I will helpfully extract for him beforehand using pliers my cat has peed on. What's that?--NO, SORRY, NO TIME FOR ANESTHETIC TODAY, DR. HUMP.
You know. One of those days.
¡A las ocho de la mañana! I know: When is Ilyka ever up at 8:00 in the morning? Answer: Tomorrow! Tomorrow Ilyka will be right up at 8:00 in the morning! Actually, 7:30! Just to be safe!
All y'all cross your fingers for me. If it goes well enough I might Paypal money TO you. I'm that freakin' pleased about this.
UPDATE: Job! Better one! More money! Fewer--nah, let's leave that unsaid. Thank you, everyone who got all yogic with the finger-crossing. Is that a word? Yogic? Yoga-like? Anyway, I love you all THIS MUCH.
One of the things I'll sorely miss about my job (which I technically still have, by the way, but check back in a few minutes, I'm sure something will have changed by then) is talking to the help desk. We have a good help desk at my company, maybe even a great one. For one thing, we don't farm the tech support out to India, WHICH IS MORE THAN YOU CAN SAY FOR WHAT WE DO TO YOUR CONFIDENTIAL HEALTH INFORMATION.
Rajeesh says he's sorry to learn about your diverticulitis, by the way.
(Checks to see if fired yet.)
Okay, where was I? Right: The help desk. Good guys. They put up with a lot, too. Medical transcriptionists--oh, let's not beat around the bush here: They tend to be older women and they tend to be technologically retarded, but in that frustrating, perpetually-apologetic way that makes you feel as if you've just yelled at your own grandma when you try to help them. So you don't want to be mean to them, but yet sometimes, you're just like, "How could you possibly do something so stupid, Grandma?"
In that vein, here's a little story I had from one of the guys at the help desk one day:
The guy's connecting to this woman's workstation via PCAnywhere, right, to help her out with something, and he's asked her way back at the beginning of the conversation, of course, whether she has a high-speed or a dialup connection.
"Huh?" she said. "I don't know. How do I tell?"
"Well, do you have a cable modem, or do you connect through your phone line?"
"Oh!" she said brightly, comprehending. "I have a cable modem."
So the guy gets on and things are going really, really slowly. So slowly he's starting to wonder about that cable-modem business.
'Ma'am, this seems to be a very slow connection--" he begins.
"Oh, it's always like this," she interrupts. "It's real frustrating waiting for the next job to load sometimes, if it's a long one. Could you maybe do something about that while I've got you?"
The guy tells her, that's the thing: He can't make her connection go any faster than what it's built to go, and by the way, is she SURE she's got a cable modem?
"Oh yes," she says, "I'm sure. I checked."
This goes on and on until somehow or other the guy's able to verify that he's on a dialup connection. And then, feeling understandably injured at this point, he asks the woman why she would be so cruel as to tell him she had a cable modem when she clearly didn't.
And she says, "But I DO have a cable modem. There's a cable coming out of it RIGHT HERE."
Ba-da bump! Thank you, I'll be here all week.
I'm sure gonna miss those guys.
Lovely, I guess I get to transcribe preops tonight. I can't stand these. Is there some med school tradition that requires future surgeons to learn how to mumble everything?
You would think speaking clearly and precisely would be more important in the business of cutting people open, wouldn't you? But you would be oh, so very wrong. Do I want to know what they sound like in the operating room? When they're further muffled by masks? I don't think that I do.
Nurse! Hand me that klaquoolfulogama!
I don't know why I bothered learning a single word of medicalese when all I really need to know how to type is the series of five underscores that indicates I have no idea what in creation this surgeon just said. Cripes. It takes a shit job like this to drive a school-o-phobe like me back to college.
Speaking of, I don't get to register until Tuesday (classes start later that week), because of oh-who-the-fuck-cares-what reason, which means next Tuesday I get to go through this all over again, only this time with lots and lots and LOTS of people half my age to go through it with me. You know what I wish? I wish I had a silver-haired wig and thick pretend glasses. I would show up to registration in the wig, the glasses, a housecoat, and my slippers. I mean, if I'm going to be old, I might as well be freaky, scary, do-you-think-she-wears-diapers, or-just-a-catheter-and-leg-bag old. I might as well be OLD old.
Um. So, that's uh, where I'm at right now. How are you?
Do you know I've had people email me to ask how to get into medical transcription? It's true. As if this were something I'd be doing intentionally.
There's some P.J. O'Rourke bit, I believe in Eat the Rich (but I'm too pressed for time to look it up), in which he explains the whole guns-and-butter economic, uh, thingie, using John Grisham and Courtney Love. The idea is, you start by assuming that Courtney Love can write trite, hacky legal fiction too, only, not as quickly as Grisham can; likewise, Grisham can write trite, hacky pop songs too, only not as quickly as Love can. And you end by concluding (after you actually, gasp, do some math--but it's very basic), that even though Love can do Grisham's thang and Grisham can do Love's thang, it's actually best, if you wish to maximize the quantity of both bad fiction and bad music, to let them each do their own hacky things, the ones they're, ah, best at.
Don't ask me why you'd want to maximize output by either of these people. Just keep the general principle in mind for a minute here.
I used to work a few places where this principle was understood and practiced. Sometimes this worked to my disadvantage--like when I worked at McDonald's and wanted to learn to work the kitchen. Management's reasoning was, "Why should we take a perfectly competent drive-thru worker, put her back in the kitchen where we can expect her to be perfectly incompetent for at least the first few shifts, and put Jorge, a perfectly competent grill cook, in the drive-thru, where he'll be perfectly incompetent for at least the first few shifts--and likely more, because Jorge no habla ingles?"
My argument was simple. Basically it amounted to: "Because if you DON'T get me out of this #$@* drive-thru VERY, VERY SOON I am going to come to work WITH A GUN. I might aim OUT the window at the customers, or I might not. It depends."
You have to loathe people a lot to beg to be closer to the grease and the grime, but believe me, after a year and a half of order taking--that's a year and a half of bitches begging me to change out their Happy Meal toys to appease Bratty and Snotty; a year and a half of assholes trying to cadge extra Monopoly pieces; a year and a half of halfwits wanting to know why we didn't serve onion rings--I really, really loathed people. Going home smelling of hamburger grease seemed a small price to pay.
But okay, management had a point: In terms of benefit to the employer, taking me out of the drive-thru was stupid.
This concept of keeping people in the jobs they're best at, so easily grasped by--for crying out loud!--people whose idea of higher education was Hamburger University, is still viewed with mistrust by my present employer.
My present employer is all, "Wait--so, you say you hate typing acute care?*"
"Yes."
"Why come?"
"Because I'm not very good at it most of the time, and even when I am, it literally bores me to sleep to transcribe."
"Well, but we're really backed up on acute care right now, so . . . ."
So you know what happens? They start routing me discharge summaries (a horror I've already complained about here before) and preoperative history & physicals and consultation notes. And I type them, poorly at worst, disinterestedly at best, half-asleep the whole time. And I don't really make much dent in the backlog. I know, go figure.
Meanwhile the ER starts backing up, as ERs are wont to do--particularly at night, which is when I work.
So the next morning, while I'm asleep, a panicked email goes out to the team from the supervisor begging for help and overtime on the backlogged ER reports. In that email, the supervisor will claim complete ignorance of any possible cause of said backlog. It is for all practical purposes a magic backlog, able to appear out of thin air.
Later, when I sign in that night, I will have a dozen emails waiting for me from transcriptionists who have no idea what Dr. So-and-So-of-the-ER is saying, and could someone please send them a sample? And they're so sorry, only, they normally work acute care and are only transcribing ER reports to "help with the backlog."
That would be, yes, the backlog that could have been relieved, possibly even avoided altogether, by letting the ER people transcribe ER and letting the acute care people transcribe acute care, the way God intended.
Really, it sounds so simple put like that.
I don't know. I shouldn't complain--I'm lucky there even IS emergency transcription anymore, since I gather a lot of places are going to this point-and-click sort of system where the doctor just fills in the damn report himself.
But do you have any idea how boring it is to transcribe a list of every conceivable risk associated with carpal tunnel surgery? I suppose I should make note of them, seeing as how it's what I'm destined for if I don't get the hell out of this line of work shortly. But every risk. Can't just say the patient gave informed, written consent, no. And maybe there's even some legal reason--hello there, HIPAA! And fuck you very much, William Jefferson Clinton--why every single risk has to be dictated, but there just is not enough coffee in the world to keep me awake through them.
It all brings up a very valid question:
If I'm going to be stuck doing work I'm not qualified to do, why am I not trying my hand at hacky legal thrillers?
UPDATE ONE: And must all specialists be imported from India?--Oh, oh, I know, I know, how insensitive of me. And I must be the only person in America with this rancid cultural insensitivity, because heaven knows I hear nothing but love coming from people who call technical support for help with their PCs only to speak with the staff in Calcutta, am I right? If you think being instructed to "rrrrreee-boot jur Vwin-doze" is fun times, you should see what that accent does to phrases like "Charcot-Marie-Tooth disorder."
UPDATE TWO: I should be fair and point out that it is actually not my immediate supervisor who sticks me with this crap--it's the supervisors covering for her. I know this because when my immediate supervisor's on duty, this doesn't happen. I love my immediate supervisor, honest. But some of the rest of the bunch haven't the brains God gave a paramecium.
UPDATE THREE: Did I have an email just now (the following day) requesting a sample transcription for an ER physician? Did that email come from a transcriptionist who normally works acute care but was "only helping out with the [ER] backlog?" Have I made a horrible vocational error? Would pounding railroad spikes into my eyeballs be a more productive use of my time? Is it poor professional form to "Dean scream" at a computer monitor if I do so in the privacy of my own home?
*This is like, the regular hospital stuff--people who get admitted overnight for observation, people who get admitted to the hospital period--versus emergency medical, your basic emergency room visits, which is the stuff I actually don't suck at.
Move along, now! Nothing to see here but childish, unprofessional, ungrateful biting of the hand that feeds.
Where to start, where to start? Oh, my: So many candidates making me want to set phasers to "KILL" today.
Let's start with physician assistants and nurse practitioners. This doesn't speak well of me, but it's the bald truth and I'm tired of hiding it:
I probably hate you.
I'm sure you're good and thoughtful people with many talents and abilities, the kind of people who give to charity and tell the most marvelous anecdotes at parties . . . I'm sure the problem with me hating you is me, that is, and not you.
But there it is. Odds are real good that I detest you.
Why? Well, because in my experience, you're almost invariably guilty of one or more or even all of the following:
1. Giving me the supervising physician's name in a big slurred rush so that neither I nor any other speaker of English can possibly decipher it.
I know you're in a hurry, but listen: I need that name, see? So slow the fuck down. I'm not so stupid as to ask you to spell it--I know you would never do that and more importantly, I know that when doctors do try to be helpful by spelling the name, they almost always spell it wrong--but, you know, maybe pronouncing it? It would be helpful to me.
2. Interrupting the dictation to confer with other hospital personnel and not putting the fucking phone on hold while you do it.
You know, it's one button. Oddly, all the M.D.'s appear to be capable of locating it and depressing it at appropriate moments. So I have to ask: Why aren't you? Is it something they teach only in medical school?
Yes, I know you need those lab results on that other patient right away, but you'd be pretty pissed off if some dingbat transcriptionist, me for example, started typing them into the present report on another patient, wouldn't you? So help me out here. Put the phone on hold! Help me not be dumb and piss you off.
As for interrupting the dictation to gossip about personal shit, well, an awful lot of you do that, too, which is even worse, and I'm embarrassed to report that a lot of you doing it are women. Quit setting the movement back forty years, bitches, and gossip on your own fucking time.
3. Playing Chinese fire drill with the report sections.
This is a flaw you do share with various M.D.s--but whereas I have some M.D.s who, in the midst of the lung exam, will suddenly inform me that the patient vomited twice last night and once this morning, requiring me to page back up to the history to insert that tidbit there--whereas I have a few scatterbrained doctors who do this occasionally, I have maybe only one or two of you P.A.s and N.P.s who don't do this like, constantly.
And guess what?--Most of the M.D.s who do this warn me first ("oh--note to transcription: Could you go back up to . . . .") or apologize afterwards ("I apologize for that. Back to physical exam . . . .") or thank me for bearing with them or even, believe it or not, all three, warning, apology, and thanks (which isn't necessary--the warning beforehand is really all I need--but it's awfully sweet nonetheless, don't you think?)--but you people? From you I get NOTHING. You're being a pain in my ass and you don't even have the courtesy to warn me that you're about to commence being a pain in my ass. I have to believe you're giving intramuscular injections to your patients sans warning, too. Not even a "this may sting a little" first.
4. Taking three times as long to say half as much.
It's a simple 1-cm laceration repair on an otherwise healthy patient. How is it that nearly every single one of you is able to stretch that out to eight minutes of yak, yak, yakking? Even residents can wrap up a suture repair faster than this. It's embarrassing. Shut up already!
I know I should just be grateful for the sweet, easy lines you give me as you yak, yak, yak about how the patient has no history of recent travel, no polyuria or polydipsia, no hematemesis, melena, or hematochezia--I got macros for all this, I should just shut up and type it in my neato macro shorthand, but fuck! You people are boring the daylights out of me!
And yeah, it's just a thought, but maybe you wouldn't have to rush-and-slur through your attending's name, the lab results, the current medications, the ALLERGIES, or any of the rest of that marginally important stuff, if you just wouldn't take eight minutes to describe a simple laceration repair.
Am I so off base about this? Is it that your attending's a real stickler for detail, a real ballbuster, so to speak? Because I notice your attending can dictate a simple laceration repair on an otherwise healthy patient in under a minute, usually. So I have a feeling I'm missing something here, but I just don't know what.
5. Slanging it up all over the place.
This sucks on accounts for which my company has been instructed not to type slang, which as of this writing is all the accounts I work on regularly.
Holy tele-for-telemetry, non-M.D.-people, but you sure do loves you some slang!
You love crit and lac and vanc and subQ and osmo and segs and you love 'em all way, way, way beyond how much even the most cryptic, shorthand-speaking M.D. loves it.
Three words: Trying too hard. Yeah, yeah, I know you're "inside" a very "exclusive," "elite" industry, one that has its own special language, its own special mystique.
That's nice. Now just say vancomycin like a normal health care provider.
6. Using the transcription as an outlet for your frustrated creative writing career.
All I'm asking for, here, is a little conformity.
If everyone else at your hospital calls that section, "Medical Decision-Making," then how 'bout you say "Medical Decision-Making," instead of "Clinical Decision-Making."
If everyone else at your hospital refers to it as "Medical History," then how 'bout you say "Medical History," instead of "History of Past Health."
If common phrases to describe successful treatment of a patient's hypertensive urgency include:
blood pressure decreased to . . . .
the patient's hypertension resolved following administration of clonidine, down to . . .
after Lopressor, the patient's blood pressure came down nicely to . . . .
patient's hypertension abated on its own . . . .
we were able to reduce his initial blood pressure to . . . .
her hypertension was alleviated with . . . .
. . . then why do some of you have to do dumb shit like say "his hypertension resigned down to 146/77 at the time of discharge?"
Resigned? Yes, okay, I can kind of see how you might think that almost works but--no. No, I lied. I can't see it. What I see in my mind's eye when you say it resigned is a cardiac monitor flashing "I QUIT" or even "TAKE THIS JOB AND SHOVE IT" where the blood pressure numbers should be.
I know it would be totally hampering your individuality and repressing your True Self to ask that you just say "decreased" when you mean "decreased" and, frankly, I don't care about your individuality nearly as much as I care about my own, and you're driving my individuality completely insane with this "resigned" shit, so KNOCK IT OFF. Decreased. The blood pressure decreased! Or "came down nicely." I admit I'm kind of fond of that one, too.
Sigh.
Don't mind me. It's just one of those days.
Pressing "play" on the footpedal, and hearing:
CHIEF COMPLAINT: Foreign body in rectum.
Somewhere up in the top 10, I imagine, is "being the person responsible for removing foreign body from rectum."
Oh, but I'm dying to tell you what the object is. We could play 20 questions from now 'til Armageddon, and you'd never guess it. Alas, I am not dying to lose my job and I'm afraid this object is sufficiently unusual that there's a real risk to patient confidentiality here.
I will say this: When confronted with a product label stating "WARNING: Contents under pressure," it simply does not occur to me to wonder, "Gee, would this fit inside my bottom? Let's find out."
This world and its people--I'll never understand it.
Then be happy I would. Mmm.
On my break from work. It's Saturday night; the ERs are stuffed to the gills with work, but what's my employer routing my way?
I bloody hate discharge summaries. Boringest things ever. And I hate cardiology notes. And admission histories and physicals. And preoperative reports. And, well, anything non-ER, basically. Acute care can suck it as far as I'm concerned.
It's not just discharge summaries, either. It's discharge summaries dictated by all the bright, young, hopeful residents and interns and . . . subinterns? I swear I just had a report dictated by someone who announced himself as that. Didn't know they even had those.
The boyfriend wanted to know what's next: Discharge summaries by candy stripers?
Probably.
Admit it: You just rolled your eyes at that title. It's such a cliche. It's right up there with . . . eh, I'm too tired to think of another example. But I know, if you're critically thinking at all, that you occasionally wonder: "Does anyone actually do that? Wear tin foil on their heads. Wait: Wear aluminum foil on their heads, I mean. Hey, and why do we call it tin foil, when it's not even derived from tin anymore?"
You say "tin foil hat," and people respond, "Right, you mean the crazies. The conspiracy nuts. The black helicopter crowd." (Hey, there's another description suffering from overuse.)
But really: No one actually covers his body in aluminum foil to ward off the imaginary bad guys anymore, right? Right? Don't we have medication for this?
CHIEF COMPLAINT: Burning in head, chest, and extremities.Yeah. THAT tin-foil hat crowd. And you thought people were just making that up to exaggerate.HISTORY OF PRESENT ILLNESS:
The patient is a 53 year-old male who presents to the emergency department complaining of a burning sensation in his scalp, face, anterior chest, and both upper and lower extremities, which he states is secondary to "being zapped by lasers from the aerial patrols." Patient states this occurs whenever he is outside. He has taken to seeking refuge in buildings, particularly on basement floors of same, and to wearing protective coverings made of aluminum foil on his person, under his clothes.
I download the sound file, press my foot down on the "play" pedal, and hear the nice physician-person say:
CHIEF COMPLAINT:
Ball in vagina.
No. No! I'm tired. He didn't really just say--
CHIEF COMPLAINT:
Ball in vagina.
What is wrong with people?
I think Dr. Alice requested a medical transcription anecdote from me a couple weeks ago. I haven't really had any of these because I am lucky: I transcribe physicians anymore who are really super-awesome dictators. (It always sounds so weird to call them "dictators," though for all I know they are that way to work with, actually.)
I mean they are so cool that when one of them dictated half a 5-minute dictation in a poorly-done Irish brogue, I not only didn't mind, I loved it--particularly when he made the aside, "this is hard!" midway through it. Yes, doctor. A good Irish brogue that doesn't sound hella cheesy is a difficult thing. I figure he did it on a dare or a bet or something. Anyway, more doctors should feel free to have fun with accents. Unless they already have accents, in which case I would like to take a moment to broadcast this request to the fine people of India:
Please: When someone praises your English--which is usually very, very good, don't get me wrong on this--please do not take that as license to speak at a rate of 300 words per minute. Because I guarantee you there are still some words you are just not pronouncing correctly at all and when you say them real fast?--Yes, thank you. I knew you would understand.
Anyway, nothing's perfect. Despite the preponderance of wonderful, clear-speaking, fabulous doctors for whom I transcribe emergency reports, there still always have to be a couple "special" cases. These have been nicknamed, without affection, Dr. Homey Don't Play That and Dr. Rules Are For Other, Lesser Beings.
You might have surmised that these two probably have the same principal flaw.
You might as well congratulate yourself because, BINGO.
See, neither Dr. Homey Don't Play That nor Dr. Rules Are For Other, Lesser Beings thinks it is worth his or her time to include such trivial information as:
--The patient's name
--The date of visit
--A birthdate?
--A sex?
--Maybe a chart number?
--Anyone? Anyone? Bueller?
And the thing is . . . the thing is . . . the thing is, we have like a system that more or less does this for the doctors. I think they have to punch in a thing or two--okay, I have no idea actually what they have to punch in, but the point is, I'm assured by my company that yes, there is a system by which they can make sure all that information is contained in the dictation without having to do very much to bring that happy circumstance about.
And the other thing is, all the other physicians do whatever that magical thing is they do to get all the patient information in the dictation already, so that I don't have to try to make out a hastily-mumbled name that HEAVEN FORBID WE SHOULD EVER SPELL, like 95% of the time. I could forgive accidents. I could forgive "sometimes" or "once in awhile." But Drs. Homey Don't Play That and Rules Are For Other, Lesser Beings? They're on more of a "never" kick with the patient information. Maybe they have a bet on with each other, I don't know.
This would be annoying, but still merely a minor nuisance, except for one other commonality these two share: Unrestrained cheerfulness and vivacity.
I mean, they leave this I-don't-know-I-kind-of-thought-it-was-maybe-important? information off all their dictations. They've been told not to leave this stuff off--trust me, I verified that much before I started complaining here--and not only are they unrepentant and determined to continue leaving this stuff off, but they both - sound - so - freaking - HAPPY - about it. Like you know the weather gals--don't tsk-tsk at me; they usually are women, admit it--that your local news stations have? These two sound like that.
"Hi! This is Dr. Homey Don't Play That Dictating on a Patient Indecipherable Lopez, whose sex, birthdate, account number or, heck, date of visit I can't be bothered to provide you! Chief complaint is nausea, vomiting, and diarrhea x3 days!" Hi! This is an underpaid transcriptionist who yearns to type, "Use the ADT feed, you cretin, or never get another report back from me again" instead of what you actually just said there!
There's nothing I can do, though. I took a survey, and I'm not the only one irritated by it, and complaints have been made, and counselings have taken place, and, you know, what can you do? These guys ultimately make the rules; they're the customers.
And Rules Are For Other, Lesser Beings.
Look, I know this is insensitive of me, and I know some of you might take this a little personally, but honestly, I mean it in the kindest way:
You would-be suicides who pop like 40 pills of this medication and 30 pills of that medication and then wind up in the hospital?
Yeah, you people . . . listen, could you maybe look the damn drugs up on the internet first and make sure they're actually going to kill you? Because otherwise the ER folks are just going to shove 50 grams of charcoal down your gut and you really won't like that; nor will you like it if you wind up with some debilitating chronic condition for the rest of your life because, baby, if you think you're depressed now, try living with hepatic encephalopathy.
(In all seriousness, if you're actually thinking of killing yourself, for heaven's sake call a hotline.)
And now not in all seriousness, let's do remember that anything worth doing is worth doing right. Right? Right!
ADDENDUM: Confidential to the would-be suicide who inspired this post: Not only do you not know which prescription drugs to take to off yourself, you don't even know where the other nonprescription drugs you're taking come from.
Which I guess is why you flipped off the sweet Asian-American physician who attended you, and told him your drug addiction was all his fault because "his country" supplies "all the drugs" in the U.S. Now honey, I typed that tox screen, so let's review:
Opium comes from Afghanistan;
Cocaine comes from Bolivia;
Methamphetamine comes from Missouri;
And THC comes from--well, okay, the best stuff comes from Thailand. But something tells me you're not smoking the best stuff. So, Mexico.
Really, I think I can be forgiven for muttering "Better luck next time" as I finished this report.