When I pulled this test out of the file folder, I started to laugh. I had even stapled the woman’s business card to it. Not that I needed it, because I distinctly remember her, and that day. She responded to an ad I placed for medical transcription contractors. I was drowning in work from a local hospital. She told me she’d been doing transcription for over 10 years, and she even taught medical transcription at a local vocational center. Fantastic. I thought I had a shoe-in.

Here are some of the highlights from her transcription test:

T: After shaving and prepped with Betadine and drapping appropriately, a semicircle incision was made in the right frontal scalp at the level of the cornal suture near pupilarly line.
E: After shaving and prepping with Betadine and draping appropriately, a semicircular incision was made in the right frontal scalp at the level of the coronal suture in the midpupillary line.

T: A reservoir was attached and secured with a 206 ligature. A shunt catheter was ___________ subgately and subcutaneously.
E: A reservoir was attached and secured with a 2-0 silk ligature. A shunt catheter was tunneled subgaleally and subcutaneously.

T: After applying stirs just in the drystill dressing after having irrigated all the wounds with Vasotracin, the patient was taken to recovery.
E: After applying Steri-Strips and a dry, sterile dressing, after having irrigated all the wounds with Bacitracin, the patient was taken to recovery.

And those are just the better parts. I never verified her work experience (obviously, there was no point), but it frightens me to think that this woman might actually have been teaching others how to do medical transcription.

This was not an isolated incident, it was just the most memorable. In the same file, I have a report transcribed by a long-forgotten MT. I probably stopped marking corrections after the first page because it’s the only page marked up.

T: Yesterday evening, she had to Margarita’s and some bay leaves.

I’m not even going to note the corrections to that – I think most readers can figure it out all by themselves.

There were very few formal education programs for medical transcriptionists at that time. Many MTs trained on the job. If they were taught by someone who had been a medical transcriptionist for years,  there was just an assumption that the person doing the training was qualified. In many cases, that was true. Unfortunately, in the rest of the cases, it was a case of the blind leading the blind. In my experience, for every medical professional in the documentation chain who knows how to spell all the words, actually reads the reports and requests/demands corrections or fills in the blanks, there are hundreds who don’t. If nobody ever tells you what you’re doing wrong, how do you improve?

If the standard measure of a qualified MT was number of years without any complaints, then the MT world would be populated with nothing but fabulous, qualified MTs.

Also in my archives is a transcript of a very (very!) old chat from the MT Daily chat room. I’m going to be surprised if any of my readers actually remember much about this site, and the chat is from 1999. The owner of MT Daily was a proponent of self-teaching, mentoring and on-the-job training for MTs. In the chat, she refers to “supraprofessionals” and “over-trained MTs.” IS there such a thing?? It seemed to me that she never quite understood that the criticism directed at her was not because she was self-trained, but because she actually promoted what many of us considered to be lower standards. There’s a problem with the approach of being promoted: nobody was making any effort to ensure that the mentors and on-the-job trainers were qualified in any way.

When overseas transcription started to become a thing and threatened the jobs and compensation rates of domestic MTs, discussions in MT communities online centered around quality (or lack thereof) from overseas transcription and how it would endanger patients and document integrity. I didn’t endear myself to the online MT community when I said there’s nothing you can say about overseas transcription that you can’t also say about domestic transcription.

If medical transcriptionists had been required to complete specific education requirements and become certified or licensed, and if all medical transcription in the U.S. was required to be done by licensed and/or certified professionals, we wouldn’t be talking (as much) about quality issues and declining compensation. But the door closed on that probably before I even stepped into my first medical terminology class, so let’s not get hung up on what-ifs and might-haves.

Resistance to the CMT credential was based largely the argument that it wasn’t a guaranty, much less indicator, of a qualified MT. You could’ve retired if you collected a dime every time an MT said “I know a CMT and she’s the worst transcriptionist!” Ironically, I never met an MT who thought someone might be saying the same about her.  By the way, I include myself in my criticisms. I have no delusions about my own beginnings and journey in medical transcription. Forever in my memory is the day I attended a one-day seminar put on by HPI (Health Professions Institute). I was running my own medical transcription business, and had about 10 MTs working for me. Looking back, I realize I was pretty wet behind the ears. I had completed a series of medical terminology and medical transcription classes, worked for almost a year at a local hospital, and part-time for a local transcription service. I thought I was not only fully qualified, but a good MT. We were having lunch and Sally Pittman was sitting at my table. I will never forget the look of horror on her face as I blithely said I capitalized all drug names because it was easier (and faster) than looking them up to see if they were brand name or generic. (Also, at that time, the American Drug Index, which was about the only reference book, printed all the drug names in a small caps font, making it difficult to differentiate generic from brand. But that’s my only excuse!) And that was the result of MY on-the-job training and mentoring. Years later, when I obtained my son’s radiology report from the local hospital, I found it was full of errors, including an elbow with possible genital abnormalities. I knew the transcription service owner who had mentored me transcribed for that hospital. And there, at the bottom of the report, were her initials.

Practice doesn’t make perfect. Perfect practice makes perfect.

I’ve told the MTs who worked for me “if it doesn’t make sense when you type it, go back and listen again!” I mean – really. A little bit of uncommon sense (common sense is not that common) would seem to be a basic first line in assuring accuracy. I have never understood how someone can type complete and utter nonsense and then defend it to the person pointing out the error. The most frequent first defense is: “That what the doctor said!” Oh sure – the doctor said a drystill dressing was applied? What is a drystill dressing, anyway? “I don’t know – but that’s what he said.” You can’t improve if you aren’t willing to admit you don’t know everything, or that you’ve made a mistake.

If you’re going to type with no more intelligence than a speech recognition program, guess what? You’ll be replaced by a speech recognition program. If the job you do isn’t appreciably better than the job done by someone in a country where people will work for a fraction of the pay, guess what? You’ll be replaced by someone cheaper, regardless of where they live. If doctors and hospitals decide they have to accept hamburger because that’s all that’s available, they won’t be willing to pay much for it.

f you look at it from the medical professional’s point of view, many of them were paying more and not getting more. Changing transcription services is a pain, which is why many are willing to continue getting mediocre service. If they’ve made the effort and switched, only to find no appreciable difference in quality, which happens too often, they become reluctant to switch again. After all, why bother? They’ve given up believing that there are any transcriptionists or transcription services doing better work. Then, they discover a good reason to make a switch: price.  They found they could pay less and get no better/worse. And there’s always someone willing to undercut everyone else’s price. As overseas transcription entered the market, the race to the bottom was on, not only in price, but in quality.

And that, folks, is my take on how the medical transcription industry got where it is today.

If I’m being really objective about documentation accuracy and accountability, and quality assessment, I’d add a category and quality point scoring system for dictation and audio, and a way to tie it back to the transcription QA score. And as usual, that’s a different post altogether and might be covered in future installments.

What I really want to talk about is blanks and policies surrounding blanks.

I’m not going to quote what you can read yourself; there’s an entire section in the AHDI document, which is linked above, and is comprehensive. AHDI has included a list of valid reasons for leaving blanks. There are unresolvable blanks, and there are resolvable blanks; i.e., valid and non-valid blanks. Non-valid blanks are blanks that can be resolved by an third party – and I’m not talking about the dictator. One would hope the dictator knows what s/he said, or intended to say. Calling a blank “non-valid” because the dictator filled it in is specious, in my opinion. I will, however, quote the following from the AHDI Best Practices document, because it bears emphasis:

Some hospitals, facilities, or organizations, however, may restrict the essential practice of leaving blanks in favor of what they call “complete” documentation. MTSOs often face pressures from their customer base to reduce and even, in extreme cases, completely eliminate all blanks. Since blanks play a vital role in healthcare documentation when used appropriately, to attempt to resolve unresolvable blanks is an unreasonable expectation and puts undue pressure on the MTSO and its HDSs [MTs] or the facility’s scribes. It is important to recognize that such a practice may encourage the HDS [MT] or scribe to hazard a guess. Guessing or making up content just to fill a blank is unethical and would require the HDS [MT] or scribe to practice their profession in a manner contrary to their training and integrity. (Emphasis added)

I see resolvable blanks as a teaching opportunity. They give a good indication of what an MT doesn’t know because they are usually the result of lack of experience and/or training. By the same token, a client demanding a “no blanks” policy also provides both a client teaching opportunity and a dilemma to anyone being asked told not to leave blanks for any reason. In my opinion, even limiting the number of “acceptable” blanks in a document is unacceptable because it still encourages guessing. (More on this later.) So my first question to a client making this demand would be “why?” What experience in their past has led to this policy? Perhaps they have had transcription services (or transcriptionists) they feel left an inordinate number of blanks; and if they asked why the blanks were left, were they unconvinced it was dictator or audio problems, or were they otherwise unhappy with the answer? Every effort should be made to educate them to an understanding of why blanks are a valid tool and necessary for accurate documentation. The dilemma arises if, even after using the opportunity to educate a client as to why blanks are valid and the steps used to reduce or even eliminate resolvable blanks, the client still insists on this policy. Call it a bad business decision, but for myself, this is a demand I wouldn’t be able to agree to. If a prospective client can’t see why there would be valid reasons for blanks, and how dangerous it is to require the transcriptionist to “fill in the blanks” no matter what, then that’s not a client I want. Experience tells me this won’t be the only unreasonable demand they’ll make.

So what about MTSOs and facilities with a set number of “reasonable blanks” they allow?

This is another dangerous policy that encourages guessing, in my opinion. The game that will be played is a guessing game of two types: guessing that someone is less likely to look closely at a document with no blanks, and guessing so as not to have to leave them. Of course, if a document happens to get audited and the MT used guessing to avoid blanks, the result is the same (or possibly worse) in terms of low QA score and any resultant consequences to the MT. Resolvable blanks are a good indication of what an MT knows or is able to learn. If the employer is unable or unwilling to implement teaching and training initiatives to reduce resolvable blanks, then the resolvable blanks will continue – as will errors. And in that case, why is the MT working for that employer at all? Demanding fewer blanks doesn’t resolve the problem, it only aggravates it; and, at the same time, jeopardizes accuracy. Applying a policy like this to all transcriptionists, rather than addressing the few MTs who might truly be leaving more blanks than would be expected, is more simple, but it is also more damaging to everyone, including the client. The same is true if the employer does have initiatives in place and no improvement is seen. At some point, if the MT isn’t teachable, both parties ought to reach a point where they agree it isn’t going to work out, and terminate the relationship. Letting it continue while applying varying degrees of punishment isn’t productive, and it damages morale. How much additional teaching and training an employer is willing to provide depends, I suppose, on the availability of MTs who might be able to complete the work without it. In my experience, unless fresh out of school, most MTs are hired with the understanding that they have the knowledge and experience to do the job without a lot of errors or resolvable blanks, and most employers simply don’t have the resources to do additional training. Regardless, a policy limiting blanks isn’t the solution to inadequate education and/or experience.

There are two other things I think contribute to the problem. One is the number of MTSOs classifying MTs as independent contractors. I’m not even going to get into whether or not the classification is appropriate and in what instances. For the most part, however, independent contractors (ICs) are people who are supposed to know how to do the job. For that reason, additional training/education by the company hiring the IC would be inappropriate, especially on an ongoing basis. I would caution any MTSO classifying MTs as independent contractors about stepping over what is already a very thin (possibly nonexistent) line. Although the IC may actually participate in some kind of continuing education, it isn’t likely to be specific to the accounts, which isn’t usually terribly helpful in terms of improvement for that service. And please don’t get started about IC status in comments – it’s another discussion entirely!

The other contributing factor is the production-based pay prevalent in the U.S. medical transcription industry. Let’s say everyone is an employee. I’ve already written about wage theft, and there are plenty of MTs who can detail how many different ways and times they’ve been subjected to it. Any employer implementing inservice training and education initiatives is going to have to be willing to pay for their employees to participate. Again, cost and resources work against this, as does the MTs’ reluctance to attend even when paid, as the hourly compensation for attendance is usually less than what they can make on production. Production pay also works against MTs taking the feedback (edits, corrections, resolved blanks) they receive and actually doing something with it. The most productive learning is to go back to the report and listen where blanks have been filled in, but that’s uncompensated time and therefore not likely to happen. I’d like to hear from MTs about whether or not they actually look at the feedback they receive, much less go back to the report to listen while they read. I’m going to guess that not many do. And why should they? They aren’t being paid for that time. One thing I did in my service was real-time QA. I asked MTs to have an online messaging service, and QA staff used a desktop program that unified several of the messenger services. If someone hit a wall where they’d have to leave a blank, they would message QA with the account, job number and time stamp. QA would pull the file and listen and work with the MT to see if it could be resolved. It was real-time, the job wasn’t held up on a circuitous journey to QA, and the MT was able to get an answer while listening to the dictation. Even if QA wasn’t immediately available or if it took a few minutes to research an answer, the MT could continue with the rest of the report, or save the report to complete when they had an answer, so productive time wasn’t wasted. They could also, of course, ask other questions, but I felt the greatest value was the near-instant learning experience. It also saved us time because we didn’t have to provide retroactive feedback (which probably wouldn’t have been read), and the client benefit was more accurate documentation and faster TAT.

Ongoing education and training initiatives are essential for improvement, especially when tied to specific dictators/accounts. Any dictator/account generating more-than-usual blanks and errors should be targeted for specific focus. Any single MT leaving more-than-average blanks and errors should be targeted for re-education or termination. Simply applying a “reasonable blanks” rule doesn’t solve anything. Just to be clear, a third party (QA staff) should have final say when determining whether a blank is resolvable or unresolvable. It shouldn’t be left to the dictator, or to the MT. Also of note, the AHDI Best Practices document doesn’t assign error points to either type of blank, but it does discuss the practices of no blanks and limited blanks. My conclusion would be that the authors do not believe even resolvable blanks should be factored in the accuracy score. If that’s the case, I would recommend that any document with blanks that can’t be categorized as valid be sent to QA for a second look and possible resolution, and that a system be in place to track data to follow trends that may be actionable.

So what about unresolvable, or valid, blanks? This is where a “no blanks” policy really falls apart. For one thing, the policy completely ignores audio quality and dictator input. You can’t make a silk purse out of a sow’s ears. I’m going to go out on a limb and suggest that clients who demand no blanks policies don’t have a clear understanding of the problems that can arise. I’m a fan of data (caveat: quality data). Tracking valid blanks and providing clients with a report would go a long way toward educating them on the valid reasons for leaving blanks. Start with the most objective ones: audio file distortion; clipped or cut off dictation; background noise obscuring dictation; inaudible dictation; unknown person or place; blank left in forwarded text to be copied; author requested; template variables not dictated. From there, try and categorize the more subjective reasons: dictator unintelligible; inability to verify dictated term or terminology; suboptimal dictation practices.

Whatever the type of blank, my philosophy is that blanks are okay, better than guessing, but for heaven’s sake make sure everything else is correct!

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?

These are questions I’ve asked myself a lot in the last couple of months. You see, I spent years obsessing over transcription done accurately. Not just accurately transcribing what’s dictated, but accurate punctuation, accurate grammar, and accurate style.

I came to MT from a background of general typing and transcription, where people actually read the letters and documents before signing or distributing them. For students writing theses and dissertations, and for professors writing papers for publication, the consequence of errors was either rejection or delayed acceptance. For attorneys, the consequences of errors could be even greater, and that includes errors in format and style. I’ve done transcription for all kinds of professional people and whether it was a letter, a document for court, a report, or an article for publication, they all read them and demanded accuracy. Even when there were no real consequences (no rejection by a judge, journal or graduate committee), they care because these documents are a reflection on them and their business.

My experience with medical professionals (read; doctors) has been quite different. After over 20 years, I still wonder whether they don’t care or if they are just that trusting. Doctors sign off on reports and letters with the most awful transcription errors. I’m not talking style, format, grammar and punctuation, either, although there are plenty of those types of errors. However, while I’m reluctant to give up grammar and punctuation, style in medical reports has pretty much become an inconsequential distraction. The AAMT Book of Style is based primarily on the AMA Style Manual, and the AMA Style Manual is intended for articles being written for publication in medical journals, not medical records. While it might be challenging to distinguish a roman numeral from the letter I, nobody seems to know (or care) whether a grade or classification is written using roman numerals or arabic numerals. The bottom line is whether there are consequences to anyone as a result of style errors. Apparently not.

The bigger issue I focus on now is wrong, missing and misspelled words. Apparently, there aren’t consequences for those in medical records, either; or at least, none that are severe enough to get doctors to read reports and demand that the words in them be accurate, and accurately reflect the intended meaning.

At this point I can’t say with any degree of confidence that there are consequences for errors of any type. How do you hold anyone accountable without consequences?

Over the years, there have been a lot of arguments discussions about the decline in medical transcription, both in the quality/accuracy produced, and in the pay scale. It’s a topic that’s been on my mind a lot since I re-entered the MT world this year.

Is it the low non-existent entry barrier? I have a friend who is a vocational counselor and she’s still shocked every time we talk about this. Virtually anyone can call themselves a medical transcriptionist and offer their services. Virtually anyone can start a medical transcription service and start soliciting customers. Even vocational programs for teaching medical terminology/transcription have no requirements or scrutiny. No license, credential, or even education is required. If accuracy is important, even critical, in these medical-legal documents, why has the low entry barrier  persisted?

Is it overseas transcription? In my opinion, that’s only part of it. There were two things that opened the door to overseas transcription. The first was digitized dictation and documentation. Let’s face it – without digitization and the internet, there wouldn’t be an MT industry overseas. The second is the low entry barrier here in the U.S. (See the preceding paragraph.) The absence of credential or license requirements for MT practitioners here in the U.S. opened the door for anyone in the world to do the same thing people here in the U.S. were doing for years; i.e., saying “I are a MT” and going into business. Digitization was going to happen; there’s nothing that would have stopped it. And honestly, who among us wants to go back to analog tapes and printing and delivering reports? (Not me.)

AAMT/AHDI tried for years to make the CMT credential meaningful, without success. In my opinion, one reason for the lack of success was that it wasn’t tied to any kind of education requirement. AHIMA has been quite successful with its credentials, but all of these require a degree from an approved education program. As much as AAMT/AHDI has been American MT’s favorite punching bag, I’m not placing the blame entirely on them. Almost everyone in the MT supply chain has some personal benefit from the low entry barrier. People already working as MTs didn’t want to have to spend the time and money on an education, credential, and continuing education. In the interest of disclosure, I am/was one of those people. Unless my clients required it, I had no interest in it, and I’m not alone in that. People wanting to be MTs had no interest – they were looking for the fastest and cheapest way to get in on what was being touted as the best work-at-home opportunity out there. And the medical professionals seem to think it’s just typing what you hear. All you need is someone who can type and maybe (and only maybe) a medical dictionary. Besides, someone with a credential or license costs more.

In that vein… put all that together and you come to what’s really important to the doctors, clinics, hospitals, etc. who utilize medical transcription services: cost.

Going way (WAY) back to discussions in the Usenet group sci.med.transcription (SMT), when transcriptionists from overseas first started encroaching on the U.S. market, U.S. MTs pointed to quality issues when making the case for good-ole home-grown MTs. I didn’t make myself popular by pointing out that anything that could be said about overseas MTs could also be said about U.S. MTs. Because of the low entry barrier, there were (and still are) a lot of really bad MTs here in the U.S. Any medical transcription service owner (MTSO) demanding accurate transcription can confirm that. Experience? Not an indicator of quality. There are plenty of MTs with little or no training or education who have confidently been pounding out error-filled reports for many, many years. Most of them are completely clueless about their lack of accuracy,  because nobody ever checked their work and/or held them accountable for it.

If you’re going to get crap, it might as well be cheap crap.

Where cost is the #1 priority, and you’re not getting what you pay for anyway, paying less to get essentially the same thing becomes a smart business decision.

Feel free to comment and discuss (respectfully, please). Since this is billed as Part One, you can expect Part Two, hopefully sooner rather than later.

On the other hand, I also believe that the companies hiring MTs have an obligation to make certain work is available so their employees have an opportunity to maximize their earnings. This is especially true in the environment of production pay. From the MTSO standpoint, I completely understand the ebb and flow of dictation volume, and the constraints of ever-tightening turnaround times. It’s a balancing act. But shouldn’t we be better at it? Shouldn’t MTSOs care enough about their employees to attempt a better balancing act?

What I’m hearing from many MTs these days is that in addition to being paid less and less, they are sitting down in front of their computers, ready to work the shift hours assigned to them by their employer – and there is no work available. In fact, the lack of available work during scheduled work shifts is the complaint I hear more often than complaints about the per-line pay rate. It seems that many MTs have accepted the pay rate as being what it is (take it or find a new career), but they’d sure appreciate the opportunity to actually earn it. Hours and days of sitting and waiting for work to appear in the queue takes its toll on the finances. Likewise, finding the work in the queue is the worst of the dictators for that account, the queue apparently having been previously combed over by an industrious cherry picker, impacts the bottom line. It is frustrating, maddening and discouraging.

And when no minimum base rate is paid, and/or minimum wage and other labor laws are ignored and even consciously circumvented by the employer (see my prior post on wage theft tactics), it deals a blow to morale, usually resulting in deterioration of work ethic. “I’m not paid enough” doesn’t always refer to the per-line pay rate, it encompasses the whole picture as reflected in the paycheck one receives. If you sit in front of your computer, waiting for work, industriously hitting the queue in those magical moments when work becomes available, for not only your scheduled shift hours but additional hours (in an effort to make up the lack of available work during shift hours), and your average hourly wage on payday comes out to $5/hour, then I would certainly agree with the statement “I’m not paid enough to do this.”

My daughter works as a personal trainer for a company that pays incentive bonuses. The base rate is very low – for a personal trainer, minimum wage. However, the bonuses are generous. Trainers have a huge incentive to make their goals for bonus. At the same time, it’s the responsibility of the gym to see that they not only actively recruit more members, but that the gym is kept maintained and cleaned, in order to keep members. It would be impossible for the trainers to sell personal training and meet their bonus goals if the gym wasn’t fulfilling its responsibilities. At the gym where she previously worked, she didn’t get paid bonuses, but the gym also didn’t fulfill its responsibility of maintaining the gym and actively recruiting members so she had the opportunity to do her job. There wasn’t a question of whether she did her best for the clients she had, there was a question of the financial impact this gym’s neglect was having on her income, and how long she could tolerate the situation.

When an employer doesn’t fulfill its obligations, what are the obligations of the employees? Do you cast aside your work ethic? Do you start cherry picking, hoarding the queue, stop looking up unfamiliar terms and spelling, stop taking the time to proofread? Or do you soldier on, doing your absolute best, either because your work ethic is intact or because you’re afraid you’ll lose the job and not be able to find another, or because you believe all companies are like this? Which raises the question – is this job better than no job or some other job?

Without debating whether or not the majority of medical transcriptionists meet the definition of low-wage workers, there were too many points in the Times article that made me nod my head and say yes, this is what happens to medical transcriptionists and I couldn’t ignore the obvious.

Wage theft, as documented in surveys, regulatory actions and lawsuits from around the country, takes many forms: Forcing hourly employees off the clock by putting them to work before they can clock in or after they clock out. Manipulating their time cards to cheat them of overtime pay. Preventing them from taking legally mandated breaks or shaving down their lunch hours. Disciplining or firing them for filing lawful complaints.

Nickel-and-diming pays well, for the employer.

Any of that sound familiar? Some MTs have filed class action lawsuits based on exactly those issues.

Let me add another one that takes a lot – and I do mean a LOT – of money out of the pocket of working MTs: not having work available during scheduled work hours, while requiring that MTs be available to do work during those hours (whether or not there is actual work), then not paying for the time they aren’t working. This is a hot button for me. If you showed up at your place of employment for a regularly scheduled shift, you might be told there’s not enough work to keep you there and you’d be sent home with no pay for the day, but I don’t know of any situation where you’d be told to sit around and make yourself available to do work – without receiving any pay. Working from home shouldn’t make it any different.

Let’s say for kicks and grins that the largest employer of MTs in the United States has 15,000 MT employees and they are required to set a base hourly rate of $10 (I’m rounding numbers here – the base in most cases would likely be your state’s minimum wage, whatever that is, unless you negotiate a higher number). Let’s say that on the average, every single MT has 5 scheduled hours a week where there is no work available. That’s 75,000 hours total. At a base rate of $10/hour, that’s $750,000 a week savings to the employer when no work is available and no base pay is paid. Since MT is a 24/7 business, I’m going to multiply that number by 52 weeks in a year. You can do the math yourself, but just for the gasp factor, I’ll tell you it’s $39 million a year savings to the employer. And those MTs? If you expect a base hourly rate of $10, your employer stole $2600 out of your pocket in one year of not paying you for 5 hours a week of not getting work during your scheduled work hours.

Let me throw out another familiar scenario. Every MT in the company is required to attend a phone conference, which is scheduled to last one hour. I’m going to be generous and say the company is going to pay a base rate for the one hour – but only one hour. OK, fine. But let’s say the conference runs over and instead of 60 minutes, it runs 90 minutes, and everyone is required to stay in the conference until it’s finished. The company can run that meeting as long as they like, but by only paying for one hour instead of the actual run time of the conference, they save $75,000 when the conference runs 30 minutes past the scheduled 60. If they require attendance but refuse to pay (no hands on the keyboard, right?), they save $150,000 per hour. And there you sit, not being compensated for attending a required meeting, while the company saves itself a big chunk of change. It’s probably not going to chap your hide when it happens occasionally, but let’s say you have bi-weekly meetings you’re required to attend without any compensation. Even if they last 30 minutes each, at a base rate of $10/hour, the company is robbing you of $130/year and you can do the rest of the math – 60 minutes, 90 minutes, every week, once a month.

How about meetings, training sessions, etc? Try reading this article: Do you pay employees for time spent renewing credentials?

The Fair Labor Standards Act requires that employees be paid for time spent in meetings, training sessions, or similar programs unless four criteria have been met:

• Attendance is outside of regular working hours,
• Attendance is voluntary,
• The session is not directly related to the employee’s job, and
• The employee does not perform any productive work during attendance.

If any one of those criteria is missing, the time has to be paid.

Do you ever wonder why employers don’t require MTs to be credentialed? Most likely because in other industries, employers have either lost a lawsuit or they’ve come out on the wrong end of a government investigation when they require a credential but don’t pay any of the expenses of getting and/or maintaining one – including time. If it costs about $500/year to maintain a credential (not including time), multiply that by approximately 10,000 employees (just for the sake of round numbers), and that employer now saves a whopping FIVE MILLION DOLLARS A YEAR. If you find that whopping, and if you haven’t read the report, consider that in three cities alone (Los Angeles, New York and Chicago), this kind of nickel and diming by employers costs low-wage workers $56.4 million a week. Let me rephrase that: it saves employers $56.4 million a week. That’s almost $3 billion a year.

We see few large companies classifying MTs as independent contractors these days. Frankly, I believe most smaller companies do it more because they simply don’t have the resources to deal with the paperwork and regulatory requirements that having employees generates. It’s a nightmare (ask me how I know). That said, it’s also a very fine line, one that most companies cross, even when they have the best intentions. For me, it would be a barrier to returning to running an MT business. Getting caught classifying employees as independent contractors will create a nightmare all on its own, leaving a small business with a choice of a rock or a hard place and likely taking its chances on not getting caught.

My favorite term in this article? Wage theft techniques. When employers don’t pay employees according to legal requirements, they are stealing from you. You may read this post and the referenced articles and get all fired up to do something. You may read it and just file the information away. The goal is to keep medical transcriptionists informed.

I feel the best single source for information is the Department of Labor Wage & Hour Division website and the DOL How to File a Complaint page. There is also a list of state labor offices, with contact information and links to each state website.

Some who seem to have found the few rays of sunshine still beaming down onto the medical transcription industry seem to have suddenly noticed that it’s dark in the room and the blinds are open – and joined me on the dark side to warn of the depressing downward spiral of medical transcription.

In a Facebook post on his Proud to Be a Medical Transcriptionist page, Jay Vance writes (in part – follow the link for the entire post):

We can debate and discuss the M*Modal layoffs specifically ad nauseum, but the bottom line is that MTs would be wise to begin casting a wider net with regard to their career future. And this is coming from someone who until recently was a diehard proponent of MT training for a career that still had some legs to it. I’m no longer comfortable with that position. My advice is to look at where the healthcare industry is going and where the demand for jobs is going to be in the next few years, and begin working in that direction.

I’m not happy about people who’ve previously insisted that medical transcription was still a viable career are finally beginning to see the writing on the wall. I’m as sad as Jay. I made good money working at home as an MT – but those days are long gone. I finally shut down my business in early 2008, primarily because all my clients either went to large companies or electronic medical records and I was left with a few doctors whose dictation was so awful it took me three times longer to transcribe their dictation, with no better dictators to offset the loss in production.

Since then, the number of MTs I see posting on Facebook and other forums about how they are making less and less money per hour, spending more and more time waiting for jobs to appear in their queue, and in general seeing the writing on the wall has grown larger and larger. Over the years, veterans have been maligned and told they’re just expecting too much, that the “good-old days” might have been better, but for people entering the field, it’s not so bad. I wonder how long those newbies worked making less than minimum wage before they finally realized the problem wasn’t just a comparison between the “good-old days” and the present reality.

I spent a lot of time learning MT. It wasn’t easy. It’s not an easy field to learn or to break into. And I feel that’s worth something. So if I compare making minimum wage as a medical transcriptionist versus making minimum wage as – say, a barista at Starbucks – I’ll choose the barista at Starbucks. Being a barista has few responsibilities, only a little training, and as long as you show up, you get paid. Being an MT, on the other hand, requires much, much more and there’s absolutely no guaranty that showing up will result in any activity that results in being paid. Soooo…. if I’m going to be paid the same amount for both jobs, I’ll take the one that didn’t require years of training and experience because I’m not going to give away my experience and training to someone who doesn’t appreciate it enough to compensate me adequately for it and treat me fairly.

And unfortunately, there is no Santa Claus, Virginia. Anyone who thinks this will all turn around just as soon as anyone whose opinion makes a difference suddenly and miraculously realizes there are errors in the records and it must be due to the fact that good-ole American MTs are no longer on the job is just deluding themselves. Turn off the sun lamp before you get badly burned; there is no comfort in false sunshine. The declining commitment to accuracy in written communications is evident everywhere. Professionals write their own letters (full of errors). Authors publish their own books, usually without any editing, and usually full of errors. Those of us who love punctuation in any form (including semicolons), well-constructed sentences, and know the difference between a possessive and a plural just cringe and cry. Everyone else just accepts it as a necessary evil of faster communication; unless, of course, they’re in the generation that just solves the problem by writing U R instead of trying to figure out if what they need is your or you’re. Doctors and hospitals are more than willing to accept a degradation in accuracy in exchange for records that are faster and cheaper. And I cannot emphasize enough the importance of the cheaper part of the equation.

Time to execute that escape plan, folks. It’s not going to get any better out there.

KRQE in Albuquerque, New Mexico reported this month that the University of New Mexico hospital has outsourced to Nuance and consequently laid off 57 medical transcriptionists. Two things to note in this news article:

One employee says many of the medical transcriptionists have worked there for 20 years and didn’t see this coming.

and

Nuance would reportedly pay a lot less than what they are currently making.

Are you still wondering if a career in medical transcription is for you?

Consider this article from the Willits News (northern California), “Changes afoot at Howard Hospital,” and this snippet of information:

“On or around April 23,” according to Parker “all the medical transcriptionists employed by the hospital will be invited to become Transcend employees.”

Is there anyone reading this who believes Transcend is going to pay these MTs a comparable wage? Think about it – if the hospital is saving money by outsourcing, then the outsource company is saving them money by…. yeah, fill in the blank.

This isn’t anything new – it’s been going on for years. But it highlights the shrinking job opportunities for medical transcriptionists. Wherever MTs go online to discuss work, you see a daily plea from someone – their company has been bought by a bigger company, or their hospital-based job has been outsourced. And when a hospital outsources to a company and their employees are invited to become employees of the outsource company, those employees soon find that they aren’t even being hired to work on the account they’ve been transcribing for the past ____ years. They know they won’t be paid a comparable rate, and their benefits will be cut. I often wonder if they also realize they’re going to be scrambling for enough lines to make a living wage while sitting around waiting for jobs that never appear in their queue.

Are you still wondering if a career in medical transcription is for you?

There are plenty of experienced medical transcriptionists who would still like to keep working long enough to get the kids through school, retire, or whatever other goals they have, and I get the impression that most of them are struggling to keep a foot in and still make a decent living. And now, there will be 57 more of them dumped unceremoniously into the job market. Unfortunately for them, they’re going to discover another ugly truth – Nuance isn’t the only outsource company that will pay them a lot less than what they’re making.

I have a lot of sympathy for medical transcriptionists who are treated the way these MTs are being treated. I understand hospitals needing to cut expenses. What I don’t understand is the mentality that dictates “we’re going to spring this on you suddenly so you don’t have a chance to screw us before we screw you.” It takes months for a hospital or healthcare system to select a transcription service. They don’t just call up a couple, ask for a quote, pick one and say “start in two weeks.” During that entire process, they have plenty of opportunity to involve their employees and prepare them for the change. Instead, they wait until the contract is signed and a transition plan in place and they give their MT employees very little time to look for alternatives. The reason the process is kept secret from the MTs is because they don’t want them looking for alternatives. They want those MTs to keep their fingers on the keyboard until they no longer need their services. They’re afraid if the news leaks too soon, the MTs will look for – and find – alternatives before the transition is complete. All legitimate concerns, mind you – but how about offering an incentive to MTs to stay on board through the bitter end?

There are usually a few things going on in the background of these decisions. In many cases, the hospital or healthcare system will require the outsource company to take on their existing medical transcription employees. This is done less out of concern for the employment and financial status of their employees and more out of concern for continuity. They believe their account will suffer less through a transition if veterans who are former employees transition with the account to the outsourced service. Unfortunately, while they may require an outsource company to offer to hire their MTs, they don’t usually think to require that those employees be kept on the hospital’s account. And because this happens all the time, I have to conclude that nobody is thinking gee, why would our MTs even go work for this company – they’ll be making half as much as they’re making now! Maybe they’re even thinking medical transcriptionists at this hospital have been overpaid for years.

Most of the time, this requirement is countered by the outsource company with the caveat that the MTs must meet their hiring requirements; once hired, they have to meet their production and QA requirements. They do not usually promise to keep them on for any specific period of time. Many years ago, as more hospitals started to outsource, the outsource company might even have courted the MTs they might acquire with an account, because they needed them. That’s no longer the case. Almost every MT I know who works for one of the large transcription services says that having enough work to do is always a problem and the solution to that is to ask to be put on more available accounts. The outsource company may agree to take on the hospital’s MTs, but there’s no guaranty that there will be enough work for them to actually make a living. Sadly, there are a lot of MTs who’ve worked for years without any quality assurance oversight and minimal production requirements; they aren’t accustomed to the demands or the scrutiny, and they aren’t able to meet the standards, so they don’t last long.

Are you still wondering if a career in medical transcription is for you?

Questions from people looking to enter the medical transcription field top the list at all my medical transcription websites. And I tell them all the same thing: I would not advise anyone at this time to start the process to become a medical transcriptionist.

Well, it’s been a busy year, and kind of an enlightening one in many respects, but I’m going to talk about enlightenment with respect to the Productivity Talk forums.

PT had been on something of a downhill slide for quite awhile, something I could see when I read through posts on the moderators’ private forum. The biggest problem was participation – there wasn’t any. There was a general belief that people visited the forum, but there was nothing in place to collect data about visitors. On other forums and in the social networks, PT got good buzz, so there was a general belief that medical transcriptionists knew about the forums and were visiting. But what were they doing while they were there? Because they weren’t posting in the PT forums!

The first thing I did was install analytics so I could start gathering statistics about visitors to the site – how many, how long they spent on the site, what pages they visited, etc. And I started digging through the forums and the slowly accumulating analytics to determine why Productivity Talk seemed to be popular with users, but to all appearances was a “dead” forum. As I archived old posts, cleaned up the site setup and added some features, I discovered something. People were visiting PT and spending a fair amount of time there- the analytics confirmed that – but they weren’t posting.

As a result, I made some changes. Previously, people could visit the forums, copy information, and download files without registering and logging in. The only thing they couldn’t do was post in the forums – so most visitors to the site didn’t even bother registering. They were there to take the available information, not to contribute or participate in discussions. I changed settings so people could only view certain forums if they weren’t logged in – a taste of PT, as it were. I also changed the settings for the more popular forums, making them available only to people who had participated in discussions on the forums (veterans). New users would need to participate to a certain degree before their membership level was promoted to allow them access to the blocked forums.

I’m not sure if people realize what it takes to run a forum (or any other website). There are hosting fees, annual fees for the forum software maintenance, plus the time it takes to validate users, clean up spam, respond to e-mails and respond to posts on the forum. It’s not a lot, and I’m not complaining, but people seem to be unaware that there are costs of both money and time. There are no ads or sponsors at Productivity Talk, and use of the forums is free of charge. I can only conclude that people don’t know this or they don’t think about it; otherwise, there’s no reasonable explanation for the response I’ve received to some of the changes at PT.

My very, very favorite ones are from people who tell me they’ve been visiting PT for years and they’ve never had to register to access the forums before. I call this group the hit-and-run group The forums that are closed except to people who’ve actively participated in discussions are the ones with the glossaries and downloads. These people have come to PT, copied and downloaded what they want, then left without any participation. They didn’t even take the time to register so they could thank the user who provided the information. They’re a little miffed that they can no longer access all the forums to get what they want, and they want me to know about it! And even though they have never once posted in the forums in all the years they say they’ve been visiting PT, they feel the need to tell me they are never going to come back to PT – and it’s my (PT’s) loss.

Waitaminnit. You’ve never registered before, never posted once – what is it PT is going to lose if you never come back?

The second group is similar to the first, but it consists of people who are new to Productivity Talk. They’re hit-and-run users in the making – or would be, if the forum settings allowed. On finding out that they must participate in discussions before they can access all the forums, they feel the need to inform me that they’ve survived without Productivity Talk for (insert years of experience as an MT) and they expect they can survive the rest of their career without it. Some of them imply that their absence is Productivity Talk’s loss, most come right out and say it.

Waitaminnit. You’re not willing to participate in the forums (and obviously didn’t read the FAQ) – what is it PT is losing?

I’m not sure what response they might expect from me, but it must make them feel better to get it out.

I’m pretty sure most people don’t understand how website owners make money, but they seem to understand that traffic (the number of people who visit) has something to do with it and therefore their visits to the site count. Let me provide some insight. I may get a warm feeling when traffic numbers spike high, but it goes away when I see that none of the visits have converted to participation in the forums. There are no sponsors and no ads, and it’s not likely there ever will be, so the amount of traffic is irrelevant.

Let me sum all this up for anyone reading who feels the same about the changes at Productivity Talk and the requirement that users participate in the forums before being given access to the “really good stuff.”

• You don’t pay to use the forums. I don’t know about you, but I was taught not to be rude about anything I got for free. I believe the common reference is don’t look a gift horse in the mouth.
• If you’ve never posted in the forums and you have no intention of posting in the forums, nobody is going to miss you if you never come back.

But hey – feel free to keep telling me how much you think you’ll be missed. I usually get a good laugh out of it before I delete the e-mail.

I’m pretty excited about it, actually – and not just because it’s a shiny object. There’s a lot of information at Productivity Talk and I think it’s useful not only to medical transcriptionists, but anyone who wants to maximize their time investment, whether it’s how they use the computer, the keyboard, or a variety of popular software programs It was at Productivity Talk (many years ago) I discovered Active Words, a great program that saved me a lot of time since I invested in a license.

I spent a fair amount of time rummaging through the site while trying (at the same time – multitasking at its best!) to figure out how the board software works. Oh yeah, I also had to move it to a new host server. I was thoroughly baffled by some custom programming that had been done for Harrie, the first owner, and it didn’t survive the move to the new server. I decided to upgrade the existing board software, which gave me some flexibility, including adding articles and videos, as well as a new home page to replace the custom programming I couldn’t make work.

If you haven’t been to Productivity Talk for awhile, come take a look and browse through the forums. Medical transcriptionists have shared an unbelievable amount of productivity information over the years. Come share and learn and stick around! I’m excited about implementing some of the new ideas I have for making the site a dynamic one for not only medical transcriptionists, but anyone who needs to be more productive.