Speaker 1: I'm Chris Danford, a second year resident at the University of Wisconsin Family Medicine Residency Program in Madison, and I'm here with John Beasley. Dr. Beasley is a professor of family medicine and coordinator of the iPractice Collaborative, which is an initiative that spans the University of Wisconsin Department of Industrial and Systems and Engineering and the School of Medicine and Public Health. John, we spend a lot of time training future physicians in medical knowledge and procedural skills, but not a lot of time teaching information mastery or how to use the new technologies that are really integral to patient care, with the result that there might be rapid changes in the way that we deliver care that happen in an unexamined way. And there might be efficient and effective technologies, like for example dictation, that are lost. I know you're a big proponent of dictating in the presence of the patient. Why is that?

Speaker 2: Well, I think there are two parts to that really. The first part, and maybe the most important, is dictating at all, because that's when you form narrative and you think through things, and you create a narrative note that hopefully will make sense to your partners. The part about dictating with the patient is it gives them a chance to understand what your thinking is, to validate it or correct it if need be. And really, to me, it's both a time and money saver too.

Speaker 1: In the sense of time, how much time is saved?

Speaker 2: A lot. I can give you a micro experiment I did with a patient of mine who was a post-hospital follow-up, late 70s. He had seven concurrent comorbidities, but I had 30 minutes, so I wasn't time pressured with him. And the dictation, which was part of that 30 minutes, was 3 minutes and 33 seconds to do his note. Then out of curiosity, once the note had been transcribed by UW, I went back and I typed the same note myself. And I'm good. I'm able to type over 50 words a minute. And it took me 13 minutes and 20 seconds, 9 minutes longer, to type that same note. That wasn't composing. It was just transcribing. I then asked a skilled Dragon user to try the same note, and for him it took him a bit over 6 minutes. So still twice as long with Dragon as to dictate into a handheld device.

Speaker 1: But there's always been the argument that transcription costs more.

Speaker 2: Well, I would argue it probably really doesn't cost much more. That same note I described, the 3 minutes 33 seconds, was $7.72 that it cost UW to transcribe that note in exchange for 9 minutes of my time. That's probably, as this business goes, still fairly efficient. And then there may be costs to not transcribing. You can make the argument that—and this is sort of back-of-the-envelope stuff, but at least a rational argument—that if we were to give each full-time equivalent physician their own transcriptionist, or the ability to dictate, that it would increase the throughput enough for the organization to come out over $20,000 a year after you paid for the transcriptionist.

Speaker 1: You specifically like to transcribe in front of the patient. Exactly. Why do you do that?

Speaker 2: Well, again, I can get feedback from the patient. I can get validation from them. And I often will stop and I'll say, did I get that right? Was that 3 months ago? Because other questions will come into my mind. I'm sure, as you know, from doing your own notes, sometimes you're halfway through the note and you think, oh darn, I should have asked about X, whatever X was. Here I just stop and I say, what about X? And they can tell me. And at the end, I say, did I get all that right? And again, they begin to notice that I covered 4, 6, or 7 problems. They begin to understand the scope of what we did.

Speaker 1: Are patients comfortable with you dictating in the room?

Speaker 2: Certainly, anecdotally, they're very comfortable with it, and I get a lot of positive feedback from that. But there are some that I don't get, or have looked for, but haven't really found, or good RCTs showing. It's only one that I know of that showed yes, patients like it. But there's really very, very good literature on the whole subject.

Speaker 1: What if there's something sensitive that comes up during the visit?

Speaker 2: Well, the patient always has access to the information in their own chart anyway. So if they want to see what you put down in here, they know exactly what I put in. And so I'm able to just kind of say, I think the patient's problems are related to their excessive alcohol consumption. And kind of the flip side of that is the patients we do know from a number of surveys are very concerned about the confidentiality and what goes into electronic records. And I tell them a lot of times, if there's something that you don't want to go into the record, but you want to tell me, you let me know, and I'll leave it out. And I do. And I just put a little marker to myself that, yeah, we discussed other issues, something like that.

Speaker 1: So what does this really look like?

Speaker 2: Well, I can certainly show you right now. We'll just pretend for a moment that you're a patient of mine, and we'll make you a 50-some year old man, and we'll start out. The first thing, Ms. Stanford, I normally dictate all my notes. I kind of like to do it right when you can listen in. And your job is to listen in and correct me if I make any mistakes. I used to use a little tape recorder for that, but I got to be all fancy and digital now. So let me dial up the transcription service here. There we go. I'm going to put in my codes, and then your patient number. Dictating now and last name Danford, D-A-N-F-O-R-D, first name Christopher, date of birth is 1-5-1958. Mr. Danford returns at our request for follow-up on problems of hypertension, diabetes, and some eczema. Overall, things have been going well for him. He's got a new job, has been more physically active, and he and his wife are exercising more, period. Problem number one, hypertension. This has been longstanding, but under relatively good control with hydrochlorothiazide and metoprolol, period. His home blood pressures have had systolic swelling in the 120s to 130s. He's had no orthostasis, no cardiovascular symptoms, period. His blood pressure today is about 132 over 80, period. Object to an examination of the chest completely clear. Heart has regular rate and rhythm without murmur, rubber, gallop. Extremities are without edema. Assessment stable hypertension plan, we're going to ask him to return in three months with a BMP prior to that and probably also do a lipid check then. Problem number two, diabetes. He was diagnosed with diabetes approximately three months ago at that time. Actually, it was more like six or eight months ago. Oh, was that six? Okay, good thing. Correction, he was diagnosed with diabetes approximately six, eight months ago, period. Started on Metformin, 500 milligrams, three times a day, which is really tolerated well without GI side effects, period. He's increased his exercise 45 minutes a day with his wife. He's watching his diet more carefully and has lost approximately six pounds in that time period. His hemoglobin A1C has dropped from 9.5 to 7.6, period. To brief examination, the sensation of his feet is intact, period. Assessment we're coming to goal here, plan, we'll follow up in approximately three months with hemoglobin A1C prior to that. Problem number three, eczema, this has been well controlled with Triamcinolone. We'll refill that prescription for him. That sound about right to you? Here we go. Yep.

Speaker 1: Okay, thank you.

Speaker 2: Amazing. And the encounter now is done. Well, I might have to drop the charges or something pretty trivial, but for all practical purposes, I'm done.

Speaker 1: I think that's really amazing. Dictation is a lost art for our residency training now, and so I'm really glad that you'd share it with us.

Speaker 2: Happy to.