INTRODUCTION
Clinical scribes who are medical assistants or nurses may not only relieve the increased administrative burdens electronic health records place on primary care physicians but also bring benefits1, 2 in documentation quality, patient care, and team dynamics3. In our previous qualitative study, patients associated clinical scribes with improved documentation quality and increased attention from their physicians 3. While most were comfortable with the clinical scribe’s presence, a few alluded to situations in which they would be uncomfortable 3. Thus, to describe quantitatively patient opinions, we surveyed patients about their perspectives regarding clinical scribes in primary care.
METHODS
A 16-item questionnaire was developed iteratively with expert oversight from a committee of practicing physicians and health system researchers. This questionnaire was pilot tested with 10 patients. Data from pilot testing were not included in the final analysis. Based on patient feedback, the option of selecting N/A for possible uncomfortable topics was added.
A convenience sample of patients 18 years or older attending routine physician visits with a clinical scribe was recruited in person from 8 physician-scribe pairs at 4 clinics from April to July 2015. Questionnaires were administered on-site after the visit was completed. Patients who were cognitively impaired, unable to provide consent, or unable to speak English were excluded. This study was approved by the Cleveland Clinic Institutional Review Board.
RESULTS
All 123 recruited patients completed the questionnaire. Table 1 summarizes patient characteristics: 110 (89.4%) were established patients; 72 (58.5%) had prior clinical scribe exposure. Eighty-two (66.7%) expressed no preference regarding the scribe’s presence; 38 (30.9%) preferred a scribe. All patients stated they would visit the physician again if the scribe was present.
Table 1.
Patient demographics
| Demographic | Number (%), n = 123 |
|---|---|
| Location | |
| Site A | 26 (21.1%) |
| Site B | 30 (24.4%) |
| Site C | 29 (23.6%) |
| Site D | 38 (30.9%) |
| Age | |
| 18–29 | 7 (5.7%) |
| 30–49 | 30 (24.4%) |
| 50–64 | 39 (31.7%) |
| 65 or over | 47 (38.2%) |
| Gender | |
| Female | 54 (43.9%) |
| Male | 69 (56.1%) |
| Education | |
| High school | 33 (26.8%) |
| Trade/technical/vocational school | 14 (11.4%) |
| College | 53 (43.1%) |
| Masters-level graduate training | 15 (12.2%) |
| Doctoral-level graduate training | 6 (4.9%) |
| Other | 2 (1.6%) |
| Race | |
| American Indian or Alaska Native | 2 (1.6%) |
| Asian | 3 (2.4%) |
| Black or African-American | 7 (5.7%) |
| Native Hawaiian or Other Pacific Islander | 0 (0%) |
| White | 109 (88.6%) |
| More than one race | 2 (1.6%) |
| Ethnicity | |
| Yes, Hispanic or Latino/Latina | 1 (0.8%) |
| No, not Hispanic or Latino/Latina | 122 (99.2%) |
| Relationship with doctor | |
| < 1 year | 22 (17.9%) |
| 1–4 years | 43 (35%) |
| 5–9 years | 30 (24.4%) |
| 10–15 years | 14 (11.4%) |
| > 15 years | 14 (11.4%) |
Eighty-four (68.2%) patients were very or extremely comfortable with a scribe of a different gender. Most patients were at least somewhat comfortable speaking with their physicians regarding smoking, alcohol use, drug use, and mental health concerns with or without a scribe. Sexual history was a notable exception (Table 2). Female patients (40/43, 79.1%) were more likely than male patients (46/60, 56.7%) to be at least somewhat comfortable discussing sexual topics in the presence of scribes (χ2 p < 0.01).
Table 2.
Patient comfort with scribe present (vs. not present). All values given in percent
| Topic | Not at all comfortable | Not very comfortable | Somewhat comfortable | Very comfortable | Extremely comfortable | p (χ2) |
|---|---|---|---|---|---|---|
| Smoking (n = 70) | 1.4 (1.4) | 2.9 (1.4) | 4.3 (2.9) | 2.4 (2.3) | 67.1 (71.4) | 0.96 |
| Alcohol (n = 83) | 2.4 (1.2) | 2.4 (1.2) | 3.6 (3.6) | 22.9 (22.9) | 68.7 (71.1) | 0.95 |
| Drug use (n = 63) | 0 (0) | 1.6 (0) | 6.3 (4.7) | 27.0 (25.4) | 65.1 (69.8) | 0.73 |
| Mental health (n = 97) | 2.06 (1.03) | 5.15 (1.03) | 5.15 (6.19) | 29.9 (23.7) | 57.7 (68.0) | 0.33 |
| Sexual health (n = 101) | 4.0 (1.0) | 11.9 (2.0) | 17.8 (22.8) | 20.8 (22.8) | 45.5 (51.5) | 0.04 |
The written record was very or extremely important for 85 (69.1%) patients. Fifty-nine (48%) patients perceived documentation to be more complete with the scribe present and 56 (45.5%) noted no difference.
Eighty-four (68.3%) patients perceived no difference in physician attention, 31 (25.2%) perceived more physician attention, and 8 (6.5%) perceived less with the scribe present.
DISCUSSION
Patients indicated no clear preference regarding the scribe’s presence or difference in perceived amount of physician attention. As most were established patients, these results may indicate baseline high satisfaction with their physician. Many patients had prior exposure to a scribe visit and might have already acclimated, which may explain why our findings related to documentation quality and physician attention differed from previous qualitative work 3. All patients would return for a visit with the physician even if the scribe remained, implying that patients may place more weight on their relationships with the physician than scribe presence. Further study should compare patient experiences with and without clinical scribes with focus on patients who decline scribes.
Though patients may be comfortable talking about most potentially sensitive topics in the presence of scribes4 in our study, sexual history presents a notable exception, particularly for male patients. Of note, all scribes in our study were female, potentially skewing our finding. Nonetheless, physicians may need to assess patient comfort level when discussing sexual history and consider offering to continue the visit without the scribe if needed. Future studies should evaluate patient-scribe gender discordance.
Limitations
Our use of a convenience sample of established patients with relative race and ethnicity homogeneity limits generalizability. Only patients who agreed to a scribe visit were available for sampling, which may lead to selection bias.
CONCLUSIONS
While not indicating a preference for clinical scribes, patients were willing to accept a clinical scribe as part of their primary care visit. Patients were comfortable with most topics except sexual history, which has implications for clinical practice.
FUNDING INFORMATION
Dr. Misra-Hebert receives funding from the Agency for Healthcare Research and Quality grant no. K08HS024128.
COMPLIANCE WITH ETHICAL STANDARDS
This study was approved by the Cleveland Clinic Institutional Review Board.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
REFERENCES
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