TY - JOUR
AU - Lammers, John C
AB - Abstract In this study we argue that professionalism imposed from above can result in a type of fission, leading to the ambiguous emergence of new occupations. Our case focuses on the US’ federally mandated use of electronic health records and the increased use of medical scribes. Data include observations of 571 patient encounters across 48 scribe shifts, and 12 interviews with medical scribes and physicians in the ophthalmology and digestive health departments of a community hospital. We found substantial differences in scribes’ roles based on the pre-existing routines within each department, and that scribes developed agency in the interface between the electronic health record and the physicians’ work. Our study contributes to work on occupations as negotiated orders by drawing attention to external influences, the importance of considering differences across professional task routines, and the personal interactions between professional and technical workers. The nature of and changes in professions are of enduring concern to scholars of work and occupations. Evetts (2003), for example, observed professionalism as a motor of occupational change, especially in knowledge work. Noordegraaf (2007, 2015) observed that the workplace, especially in the public sector and in healthcare, constitutes an ambiguous domain that concerns issues of control and incorporates organizational aspects, such that organizing for quality has become a central ingredient of professional work. Reed and Thomas (2019: 1) also studied the ‘indeterminate’ nature of identities as a part of the professional role. Each of these authors is concerned with the uncertain and changeable character of profession. As professional work is occurring more often within employing organizations, where professionalism is being imposed ‘from above’ as opposed to originating from within the work itself, the idea of professionalism is used to advance behaviors that the organization or institution deems appropriate, effective, and efficient (Evetts 2011, 2013). Professions are negotiated orders, always in a process of change between ‘ruled and unruled behavior’ (Strauss et al. 1963: 151; Bechky 2011; see also Cheney and Ashcraft 2007). This is often because of developments in technique and emerging ‘segments’ of work (Bucher and Strauss 1961: 326); as new techniques develop, cleavages appear that presage the emergence of a new occupation. Dingwall (1983: 606) described the emergence of new occupations generally as a process of fission: ‘work becomes more complex and the division of labour more specialized through the dissection of occupations’. Studying the process of fission in a profession requires attention to established routines of work as well as currently malleable and emerging practices. As traditionally conceptualized, fission results from internal work complexity leading to the splitting of tasks. We argue that professionalism imposed from above (e.g. Evetts 2011) can also result in a type of fission; for example, the new public management (Kessler, Heron and Dopson 2015), or in the case we present, the mandated use of electronic health records (EHRs). This article addresses the messy ambiguity of ‘what is an occupation as it emerges from professional fissure?’ In the USA, federally mandated EHRs have created a fissure in physicians’ work by adding tasks inconsistent with their traditional activities, understandings, and beliefs about medical practice. In response, many have turned to medical scribes, who accompany physicians as they examine and treat patients, recording into EHRs the information required to document an instance of medical care. Although their activities are entwined with those of the physicians, the work requires ongoing negotiation over the new role. When and how physicians delegate tasks to scribes, or incorporate additional tasks or specialties into their own existing work domains, influences their overall role and task repertoire in healthcare teams (Bossen, Chen and Pine 2019). Although scribes are treated as a new occupation, our observations of physicians and scribes working together show unexpected shifts in roles and task awareness that grow out of the particular routines adopted by physicians in different specialties. Kessler, Heron and Dopson (2015) summarized task changes resulting from external pressure in terms of two professional logics: specialist-discard, attributed to Abbott (1988) and Hughes (1993), and holistic-hoard, attributed to Bucher and Strauss (1961). A specialist-discard logic assumes that professions work to acquire high-status roles and skills and delegate (or discard) less desirable tasks to subordinate groups (Kessler, Heron and Dopson 2015). Thus, physicians might recruit scribes to perform technical tasks involving EHRs which physicians deem outside of their professional expertise. A holistic-hoard logic, on the other hand, suggests that the concept of a clear professional core is problematic; instead, professionals may hold different conceptions of what constitutes the core of their work and attempt to maintain control over all aspects of their work (Bucher and Strauss 1961; Kessler, Heron and Dopson 2015). Examining the boundary work (Liu 2018) of physicians and scribes can offer insight into the rise of a new occupation resulting from professional fission. The emergence of medical scribes has been discussed as a new data-driven occupation in health care, but most existing scribe literature focuses on economic efficiency, documentation accuracy, and physicians’ work satisfaction (Bossen, Chen and Pine 2019). Research is missing on the interactions between medical scribes, physicians, and patients, how scribes interact with EHRs, and how scribes perceive their work (Bossen, Chen and Pine 2019; see also Shultz and Holmstrom 2015). These interactional aspects of occupational emergence draw our attention to boundaries between professions and occupations and the fluidity of roles. Moreover, because there are few regulations in place for this new occupation, there is concern over ‘functional creep’, or the risk that the emerging scribe role will creep into areas that many argue require medical licenses (Bossen, Chen and Pine 2019: 78). Evetts (2011: 415) specifically called out ‘unintended’ consequences on the prioritization and ordering of work activities, as increased regulation and form filling take time that was formerly spent on clients. Furthermore, the standardization of work procedures entailed in software programs can be both a check on an underachieving practitioner but also a disincentive to the ‘creative, innovative and inspirational professional’ (Evetts 2011: 415). Thus, our study aims to understand how professionals manage a mandated fissure in their role as a result of a policy that targets individual physicians, and how this is reflected in physicians’ work as they now balance professional, organizational, and technological requirements. Below, we first offer a brief overview of EHRs, physicians, and medical scribes in the USA as the key elements of this professional fission, followed by our research questions, design, study site, and findings. In our conclusion, we return to the importance of looking at messy and ambiguous work routines in addition to roles, as professional fission creates space in which new occupations may be transient or become established. EHRs, PHYSICIANS, AND SCRIBES EHRs The EHR has a formidable role in US health care policy making (Berg 1999; Håland 2012; Proulx, Bryan and Lammers 2016). The American Recovery and Reinvestment Act of 2009 included a $19 billion program labeled the Health Information Technology for Economic and Clinical Health Act (HITECH). The Office of the National Coordinator of Health Information Technology created a strategic plan for a nationwide interoperable health information system, relying on EHRs to achieve improvements in quality and efficiency of health services (Blumenthal 2010). In 2008, only 17% of physicians and 9% of hospitals used an EHR, but by 2017, 79.7% of physician offices and 96% of hospitals used certified EHR technology (Office of the National Coordinator for Health Information Technology 2017, 2019). Much of this rapid growth can be attributed to HITECH and, more specifically, the Medicare and Medicaid EHR Incentive Program, which specified criteria providers needed to meet to demonstrate they were ‘meaningfully using’ EHRs to improve patient outcomes to avoid reimbursement penalties. Thus, physicians have faced a hard mandate in the use of EHR technology. Physicians US physicians spend more time with EHRs than with patients (Poissant et al. 2005), leading to physician dissatisfaction with EHRs (Lammers et al. 2016; Barrett and Stephens 2017; Barrett 2018). Although Rutten et al. (2014) identified EHR use as having positive effects on patient care outcomes, disease-specific clinical outcomes, intermediate outcomes, responsiveness to the preferences of patients, shared decision-making, patient–clinician communication, and access to medical information, physicians continue to struggle with EHR usability. A lack of usability, low computer literacy in patients and clinicians, insufficient training in Health Information Technology (HIT), physicians’ concerns about more work, depersonalization, incompatibility with current practices, and lack of standardization are some of the problems physicians face when incorporating EHRs into their workflow (Shultz and Holmstrom 2015). Although the promise of EHRs is to ‘allow access to evidence-based tools that providers can use to make decisions about a patient’s care; and automate and streamline provider workflow’, they constitute ‘a fundamental, constitutive element of medical practice’ (Berg 1996: 499; Healthit.gov 2013; see also Frankel 2016). The EHR is therefore more than an electronic version of a paper record of patient care (Berg 1996, 1999; Morrison et al. 2014). For example, the EHR is programmed to provide clinical decision support reminders and alerts in the form of pop-up screens that many providers find distracting, leading to providers overriding or ignoring reminders that are meant to protect patients (Bryant, Fletcher and Payne 2014). Facing this fissure in their work, partly in resistance to EHRs and partly in an effort to re-define their expertise, many physicians have begun to rely on medical scribes as a human interface with the EHR (Gellert, Ramirez and Webster 2015). Scribes Paid between $8 and $16 per hour, scribes typically receive several weeks of training in medical terminology and EHRs (Hafner 2014). Although the use of scribes and EHRs is met with some concern (Anonymous 2014; Bodenheimer, Willard-Grace and Ghorob 2014), most studies report high satisfaction on the part of physicians (Gellert, Ramirez and Webster 2015; Hess et al. 2015). Indeed, the use of scribes has been found to improve not only clinician satisfaction, but productivity, time-related efficiencies, revenue, and patient–clinician interactions as well (Arya et al. 2010; Koshy et al. 2010). As Shultz and Holmstrom (2015) observed, however, few studies have compared scribes working in different specialties or departments. The emergence of scribes in the USA has been so sudden and widespread that they are as yet uncounted by government or trade organizations. Current estimates in the USA exceed 20,000, and expectations are that the number will grow to over 100,000 in the next 10 years (theacmss.org). Moreover, scribes are following a familiar path toward professionalization, with a statement of ethics, a stable training curriculum, a professional association (The American College of Medical Scribe Specialists), and a scholarly journal (Medical Scribe Journal). Sixty percent of scribes work full time, and they are expected to become stable members of the health care workforce (Santiago n.d.), sometimes referred to as ‘personal productivity assistants’ (Kayden et al. 2014: 218). However, they are also highly focused on the use of the EHR and health care productivity improvement (Wenger 2015). Although there are no formal regulations regarding scribe use, the Joint Commission suggested the following definition: A documentation assistant or scribe may be an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other licensed independent practitioner (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure (The Joint Commission 2019). Details, such as the specific role, responsibilities, and amount of training, are left to individual organizations and physicians to decide. As such, one unusual feature of the scribe role is that their activity is not cleanly segmented from that of the physician, which means that the work is negotiated at the level of daily activities (Bucher and Strauss 1961). Current evidence suggests, then, that scribes may be described as a technical occupation as they lack the capacity to exclude other groups (Murphy 1988). However, while their work is attached to a technology (Orr 2016), it is also very much intertwined with that of physicians, and in some cases evenly shared. A meta-analysis of medical scribe literature identified economic feasibility and satisfaction on the part of physicians and patients as primary research foci (Bossen, Chen and Pine 2019). That analysis also noted that scribes have been studied in a variety of settings, including emergency departments, cardiology, urology, ophthalmology, primary care, without comparing these settings or routines (Bossen, Chen and Pine 2019). Thus, we endeavored to study scribes across more than one setting, which drove our first research question: RQ1: What differences, if any, are apparent in the roles and routines of medical scribes between different hospital departments? Additionally, because existing literature focused primarily on documenting outcomes of scribe use, we sought to understand how the addition of scribes impacted interactions around EHR use and patient care. Our second research goal was to understand how the scribe–physician work roles and routines were negotiated at the site of daily activities: RQ2: What is the nature of the roles and routines shared by scribes and physicians? In the next section, we describe the location of our study and the approach we took in examining the interaction between scribes and physicians. RESEARCH SITE AND STUDY DESIGN The second author wrote the initial project proposal and gained access to a community hospital in the Midwestern USA. The 413-bed hospital annually discharges approximately 27,000 patients and treats over 63,300 patients in its emergency room, and uses Epic Systems as their EHR vendor. Both the hospital and our university Institutional Review Boards approved the project. Informed consent was obtained from all study participants, with the physician introducing the researcher to patients and verbal consent acknowledged before exams began; no protected health information was recorded. The first author completed all observations and interviews in the two departments employing scribes: Digestive Health (DH), which was just starting a scribe program, and Ophthalmology (O), which had used scribes for several years. Due to the new nature of scribes in DH, study plans entailed three rounds across a period of 12 months to observe how DH scribes settled into their roles in the department (see Table 1). During the study period, participants in Digestive Health included five physicians and three scribes, while Ophthalmology employed four physician–scribe pairs. Table 1. Summary of data collection . Round 1: Winter . Round 2: Summer . Round 3: Fall . Total . . DH . O . DH . O . DH . O . . Hours of observation 43.5 33.5 38.5 34 21 13 183.5 Number of scribe shifts 12 8 10 8 6 4 48 Patients seen 89 150 81 137 49 64 571 Single-spaced typed notes 65 44 102 86 52 30 379 . Round 1: Winter . Round 2: Summer . Round 3: Fall . Total . . DH . O . DH . O . DH . O . . Hours of observation 43.5 33.5 38.5 34 21 13 183.5 Number of scribe shifts 12 8 10 8 6 4 48 Patients seen 89 150 81 137 49 64 571 Single-spaced typed notes 65 44 102 86 52 30 379 Open in new tab Table 1. Summary of data collection . Round 1: Winter . Round 2: Summer . Round 3: Fall . Total . . DH . O . DH . O . DH . O . . Hours of observation 43.5 33.5 38.5 34 21 13 183.5 Number of scribe shifts 12 8 10 8 6 4 48 Patients seen 89 150 81 137 49 64 571 Single-spaced typed notes 65 44 102 86 52 30 379 . Round 1: Winter . Round 2: Summer . Round 3: Fall . Total . . DH . O . DH . O . DH . O . . Hours of observation 43.5 33.5 38.5 34 21 13 183.5 Number of scribe shifts 12 8 10 8 6 4 48 Patients seen 89 150 81 137 49 64 571 Single-spaced typed notes 65 44 102 86 52 30 379 Open in new tab The first author completed 103 h of observations that included 219 patient encounters in Digestive Health, and 80.5 h of observations that included 351 patient encounters in Ophthalmology. Across both departments and all rounds, a total of 48 scribe clinic shifts were observed for a total of 183.5 h. Field notes were handwritten during observations and typed after every observation. Both authors contributed to the interview protocol, which included questions such as ‘are there any benefits or concerns about using EHRs that are significant to you?;’ ‘how do you think EHRs have changed how you interact with others?’, asking each physician interviewee to describe their history with scribes and EHRs, and asking each scribe interviewee about becoming a scribe and their experiences with EHRs. During Round 1, seven physician interviews occurred in their office between patient visits or during their lunch periods, and five scribe interviews occurred before or after their shifts. Scribes were interviewed in an unoccupied scribe prep space, a section of desks and computers for nurses and physician assistants to use and where the scribes kept their personal items, or in an empty patient exam room. All interviews were recorded and later transcribed by a third party, and verified by the researcher who conducted the interviews. In the presentation of our results, physicians and scribes are given pseudonyms. We followed recommended procedures for inductive qualitative data analysis (Gioia et al. 2013). The transcription of the handwritten observation notes was the foundation for reflexive data analysis. During Round 1 of observations and interviews, the authors met weekly to discuss the data, create summary memos, and reflect on similarities or differences noted between departments. At the end of Round 1, we engaged in open coding of the transcribed formal interviews and reflected on fieldwork observations to note emerging themes related to RQ1. The first author subsequently discussed the primary differences between departments with both physicians and scribes in each department, resulting in additional informal conversations about how the observed differences reflected the type of work done in each department. As the differences between departments became clearer, observations during Rounds 2 and 3 focused on the nature of the relationships between the scribes and physicians. We then engaged in open coding of all of the data using descriptive words to describe what we saw within the data, followed by a second round of coding specifically focused on labeling instances of interaction between physicians and scribes. This allowed us to look for similarities and differences between both departments and between physician–scribe interactions. Next, we relied on axial coding to collapse our open codes into a smaller group of second-order themes (Strauss and Corbin 1990). In what follows, we first describe differences between the structure of the work of medical scribes and physicians in two departments (RQ1), followed by a discussion of the influence of the EHR and the nature of roles and routines shared by scribes and physicians (RQ2). DEPARTMENTAL DIFFERENCES Our fieldwork showed that the established work practices influenced the incorporation of scribing tasks into workflows (see Table 2). Through observations, formal interviews, and informal conversations with scribes and physicians, we learned that ophthalmology physicians worked with ophthalmological assistants (OAs) who were also trained to scribe, whereas the Digestive Health department contracted with a national firm that trains and places scribes in hospitals and clinics. This difference flowed from the types of work physicians do in each department. The regular work in Ophthalmology consisted of routine and repeated examinations of patients’ vision, with physicians considering scribes as the most effective when they could assist with patient examinations and place prescription orders. Therefore, Ophthalmology selected certified ophthalmology assistants who had worked in the department for at least a year to scribe for a specific physician, meaning they were licensed to assist with patient exams and place orders, and utilized them as traditional assistants when the physician was not in clinic. In contrast, digestive health physicians consulted with patients typically for the purpose of investigating or treating digestive health complaints. As such, digestive health physicians relied on in-depth patient history summaries that required detailed notes and did not include routine treatment assistance. Digestive health scribes were therefore contracted to work only during clinic hours, were employed on behalf of the hospital by the placement firm, and were typically undergraduate (or recently graduated) students planning on a medical career. This meant they were not attached to the routine work of the Digestive Health department. Table 2. Comparison of physician work, use of scribes, scribe origin, and scribe place in ophthalmology and digestive health departments . Ophthalmology . Digestive Health . Physician work: Often routine examinations with repeat patients, or clear presentation of specific ailment to be treated Investigating or treating one-time digestive health complaints; relied on in-depth patient history Physician use of scribes: Assist with patient examinations and placing prescription orders Detailed notes of patient history and treatment plan; much variation across physicians Scribe origin: Ophthalmology assistant for at least one year in the department Contracted from a national firm, often undergraduate or recently graduated students planning on a medical career Scribe place within department: Paired with a specific physician and trained to scribe during physician clinic hours; ophthalmology assistant when physician was not in clinic Contracted to work only during clinic hours; paired with a physician in clinic during their scheduled shift . Ophthalmology . Digestive Health . Physician work: Often routine examinations with repeat patients, or clear presentation of specific ailment to be treated Investigating or treating one-time digestive health complaints; relied on in-depth patient history Physician use of scribes: Assist with patient examinations and placing prescription orders Detailed notes of patient history and treatment plan; much variation across physicians Scribe origin: Ophthalmology assistant for at least one year in the department Contracted from a national firm, often undergraduate or recently graduated students planning on a medical career Scribe place within department: Paired with a specific physician and trained to scribe during physician clinic hours; ophthalmology assistant when physician was not in clinic Contracted to work only during clinic hours; paired with a physician in clinic during their scheduled shift Open in new tab Table 2. Comparison of physician work, use of scribes, scribe origin, and scribe place in ophthalmology and digestive health departments . Ophthalmology . Digestive Health . Physician work: Often routine examinations with repeat patients, or clear presentation of specific ailment to be treated Investigating or treating one-time digestive health complaints; relied on in-depth patient history Physician use of scribes: Assist with patient examinations and placing prescription orders Detailed notes of patient history and treatment plan; much variation across physicians Scribe origin: Ophthalmology assistant for at least one year in the department Contracted from a national firm, often undergraduate or recently graduated students planning on a medical career Scribe place within department: Paired with a specific physician and trained to scribe during physician clinic hours; ophthalmology assistant when physician was not in clinic Contracted to work only during clinic hours; paired with a physician in clinic during their scheduled shift . Ophthalmology . Digestive Health . Physician work: Often routine examinations with repeat patients, or clear presentation of specific ailment to be treated Investigating or treating one-time digestive health complaints; relied on in-depth patient history Physician use of scribes: Assist with patient examinations and placing prescription orders Detailed notes of patient history and treatment plan; much variation across physicians Scribe origin: Ophthalmology assistant for at least one year in the department Contracted from a national firm, often undergraduate or recently graduated students planning on a medical career Scribe place within department: Paired with a specific physician and trained to scribe during physician clinic hours; ophthalmology assistant when physician was not in clinic Contracted to work only during clinic hours; paired with a physician in clinic during their scheduled shift Open in new tab When considering how scribes are integrated into departments, Woodcock et al. (2017) identified three staffing models: a licensed model, in which certified healthcare assistants or technicians perform scribe duties; a commercial model, in which scribe staffing companies provide scribes; and a student model, in which premedical students act as scribes. In addition, they found that scribes may be pooled in a many-to-many relationship with providers, dedicated in a one-to-one relationship with providers, or work in a hybrid structure where a single scribe worked with several providers (Woodcock et al. 2017). Within Ophthalmology, our data reflect the licensed model by attaching the scribe role to a pre-existing OA role, in a dedicated one-to-one relationship (Woodcock et al. 2017). In Digestive Health, our data reflect the commercial model, creating the scribe role de novo in a pooled many-to-many relationship (Woodcock et al. 2017). Why a department would select one model over another, however, was not addressed by Woodcock et al. (2017). From our observations, physician workflow influenced the selection of the scribe staffing model and led to substantial differences in the success of the scribe–physician relationships. In both departments, physicians had advocated for scribes to assist in working with EHRs based on the type of work routines their specialty required. Dr Shalaby explained that she initiated a conversation about scribes as she was concerned that without a scribe the patient load would be too heavy: I was nervous going from the patient load I had there [previous hospital] to coming here. So I started reading about scribes. And I actually asked about it when I interviewed. And then Dr. Bukar was [also] interested in the idea. In Ophthalmology, Dr Kowalski expressed the same motivation: ‘I think I’ve just pushed it from the very beginning, and I just said in this system I’d be much more efficient. And so eventually they just kinda – they bought into it’. While physicians initiated Digestive Health’s contractual use of medical scribes, physicians could opt-in by splitting the cost with department on a 1-year renewable contract. As contracted workers with no medical training, digestive health scribes were not legally allowed to interact with the patients. This constraint affected their workflow through various measures, such as physicians introducing them to patients as note-takers and by physically placing themselves out of the direct line of sight of patients. In contrast, the type of scribe work the ophthalmology physicians wanted meant that existing OAs were paired to scribe for a specific physician, with the expectation that as trained medical assistants they would interact with patients as part of their regular duties. Scribes accommodated physicians’ preferences in both Ophthalmology and Digestive Health. In Ophthalmology, because each of the scribing OAs was permanently paired with a physician, this became routinized more quickly with scribes working regularly with the patients along with a particular physician. In addition, physicians in Ophthalmology expected their OAs to balance the role of scribing and assisting. For example, the researcher often observed scribes preparing patients for the physician visit if the scheduled OAs were busy in order to keep the physician on schedule, although this was an OA responsibility. Because of this dual role, OA scribes had a substantial relationship with their department beyond scribing. Thus, the scribing routine became normative: what physicians expected the scribes to do during an exam, how they did it, and how they worked with the physician outside of exams (for things such as surgery schedules, special accommodations for patients, or follow-up paperwork) all merged into a single role. In Digestive Health, in contrast, the many-to-many scribe–physician relationships meant scribes had to learn different physicians’ styles. Because EHR noting is detailed and complex, this could be problematic. When asked about working with multiple scribes, Dr Bukar observed habits a scribe had brought in based on other physicians’ preferences: A few times before, she had included some of the so-called garbage that patients would talk about, and personal things, and she’s learned that with me, that’s not very important in documentation. But I’ve seen, based on what she had done for me before, that she was used to putting [in] these notes with other providers. For me, I try to filter those background noises out of my notes. Although the scribes noted physician preferences in terms of writing style and formatting, they also tested out similarities if a physician commented that they particularly liked something. When discussing the recommendations section of the EHR note with the researcher, for example, Yasira commented, ‘I used to put it in paragraph form, and I realized nobody likes that…[Dr. Yassin suggested] let’s separate it line by line’. Yasira began formatting the recommendation section that way for all the physicians, and after realizing all of the physicians she worked with liked the new formatting as well, kept doing it. When asked about training during an interview, both scribes described a lengthy training schedule where newly hired scribes would spend a week going through Digestive Health lecture materials, some provided by the contracting firm, but extensively supplemented by the current scribes as they considered what the new scribes needed to learn on the job. Once the classroom training was complete, new scribes would shadow a current scribe for at least a month, learning how each physician liked their notes, gaining a more detailed understanding of the types of patients each physician usually saw, and the common medical terminology physician used. This also demonstrates the trial and error, learn-on-the-job process Digestive Health scribes talked about, referring to the lack of sufficient training and how they figured out, based on physician feedback and suggestions, what to continue doing, and what needed changing. They tried to share this information with each other and incorporate it into new scribe training practices, but the responsibility fell on them to train other scribes, rather than the physicians creating material that described what they preferred. For example, during one observation day Yasira was training Juan, so although the researcher was unable to follow the scribes into the exam rooms due to lack of space, she was able to observe the informal training process in the hallway in between patients. Early in the shift, Yasira was explaining the charting preparation process to Juan: Yasira: So they have tabs for cardio, eye…you can open notes. I have these tabs, I can make them for you if you want, it sorts by GI. So she was last seen… (types in note) “[patient] was last seen by me” – write in the first person because you’re writing for the doctor – on [date]. (she types a few more items) Ok, that’s it for that section. Now, down to procedures. Ignore all the other work ups, she’s older so she’s had a lot of visits. (Yasira reads a few out loud as she skims the list; brain, etc.) Ignore the ones not related to the abdomen. Her last endoscopy, colonoscopy. I copy paste this part. I underline the test name. It’s just easier to read. Other scribes did different things, I find this to be the best because it’s the easiest to read, since it’s a lot of text otherwise. Juan: So you just copy and paste that? Yasira: Yeah. Yasira also made a point to do all of her wordsmithing out loud, knowing Juan was watching her work. When she felt it was necessary, she would add commentary about her process, once interrupting herself: ‘Hold on. I don’t like saying the same thing… (deletes the start of her sentence) We will schedule her for a…’ In this way, she was able to demonstrate to the new scribe how she translated information from the exam room into complete sentences, including her editing process in terms of writing style. In addition, she would add commentary about her inclusion/exclusion criteria: ‘So this is a patient history chart…most are from the 70 s so I’m not going to include any of it because it’s not relevant now. Unless she brings it up in the room, then I’ll include it’. Here, she was able to explain her reasoning about when she would or would not include specific information for this physician. While this technical information was necessary for the new scribe to know, Yasira also commented on general workflow. For example, while in the hallway after a patient exam, Dr James walked with the patient to the checkout desk. Yasira made a point to tell Juan that Dr James always does that, thus indicating that there was no need for them to follow Dr James but instead they could wait in the hallway until she came back for the next patient encounter. These types of nuances were not articulated by the physician, but were considered the important aspects of their work that established scribes attempted to pass on to new scribes. Thus, in Digestive Health the training of new scribes began with established scribes rather than learning directly from physicians, as in Ophthalmology. When asked about training, the most established three Ophthalmology scribes described how they learned on the job with their physician, but with the addition of the fourth scribe they had the resources to initiate a new training process where a new scribe would shadow current scribes before starting work with their paired physician. In the newest scribe’s experience, since she was working with a new-to-the-department physician, it was also an opportunity for her to teach her physician about Epic and the department. It was understood that each physician had different specialties within Ophthalmology and different preferences, so the scribes were careful to focus on overall workflow and general expectations rather than specific documenting techniques. The scribes also held a monthly meeting where they discussed what each did that might be useful in their own work and developed a formal scribe training book, and later traveled to an Ophthalmology scribe conference together. Thus, although the first scribes learned ‘on the job’ with their paired physician, once they had enough resources they switched to a ‘scribe-teach-scribe’ model similar to Digestive Health. In sum, we found substantial differences in the scribes’ roles in the Ophthalmology versus Digestive Health that emerged out of fundamental differences in the work itself, as well as the choice in one department to dedicate particular scribes to particular physicians. NEGOTIATING ROLES AND ROUTINES IN THE CONTEXT OF THE EHR In response to research question 2, we organize our findings around the nature of roles and routines shared by scribes and physicians by first describing how EHRs structure work, followed by the differences in roles and routines between Ophthalmology and Digestive Health. EHR structuring work Our participants seemed aware that EHRs had a subtle effect on work processes independent of scribes’ presence. According to Dr Caru, ‘…the really poignant part is, it gets into the head of the practitioner in such a subtle way that … I believe that these EHRs actually leverage how we medically problem solve’. When asked a follow-up question confirming whether he meant items such as pop-up boxes or required check boxes, Dr Caru offered a counter question: ‘do you shop the same way online as you do if you’re in Nordstrom’s?’ Bringing the topic to algorithms, he continued, ‘when you wanna point and click, there’s a certain efficiency with how you wanna move through an algorithm. And also, the algorithm constrains you’. Warming up to his argument, he elaborated the following: Now this is a merely hypothetical question, but do you want your doctor constrained? Do you want your doctor shopping at Zappos? Or do you want your doctor looking around – it’s not a simple question to answer. Zappos will show you more shoes. But if you’re at Nordstrom’s, you can try them on. Sometimes you have to stroll – and that’s the part that’s critical in medicine. Sometimes, you gotta go to Nordstrom’s. You gotta go to the store. Because you just can’t get it online. Or you just don’t have the support you need. … it’s like any other piece of technology. I mean, the stethoscope was anathema because it actually took your hands off the patient. Can you imagine a rubber tube between you and your patient? How are you supposed to find anything out with a three-foot rubber tube between you and your patient? It’s the same thing. Thus, Dr Caru recognized the constraints imposed by the EHR and was contemplating whether the EHR would eventually be integrated into routine work. When asked if a scribe could be considered that extra distance between the physician and the EHR, Dr Caru expressed ambivalence about the how the addition of a scribe would help: But the hypothesis is that I need a scribe to make me more efficient, to make my work experience more enjoyable for me, to make it better for my employing institution – because I can now see more patients – and to make a better experience for the patient. But another human being to do that, seems silly. In this case, Dr Caru found it ironic that the process of adding a new technology with the intention of helping him be more efficient required a second human in the room. On the other hand, in Ophthalmology, both the physicians and the scribes seemed more convinced of the benefits of having a scribe. When asked about if or how being in the room changed the patient–physician interaction, Mandy commented about the physician she worked with: She’s (Dr Bohoora) kind of a fiddler, so she’ll click around and look at things and not really look at the patient a whole lot. I can do all the computer stuff, which kind of forces her to look at the patients, which a lot of patients love. They actually have said to me, ‘I’m thankful for you because she’ll actually sit and she’ll talk to me now,’ instead of them talking to her back. Dr Bohoora agreed that the division of labor worked: ‘And it just kind of frees your mind to concentrate on the patient instead of the paperwork’. In addition, Ophthalmology patient encounters required much more extensive physical exams compared to Digestive Health, and in some cases, patients came to Ophthalmology for injections on a regular basis. This routine included the initial eye exam, followed by numbing of the eye and then the injection itself. As Dr Kowalski described it, I guess there were certain flow things that we had to work out some kinks …. In the end it becomes almost like a dance kind of thing, ok? If I’m sitting down and I’m already charting, why do I need to get up and start numbing the patient…or vise-versa. Here, Dr Kowalski noted that even though he expected Lisa, his scribe, to help with the electronic chart, if he happened to get to that stage before Lisa entered, he expected Lisa to step into the OA role and assist with numbing the patient, while he continued in the scribe role. In this way, both the scribe and the physician needed to understand the routine of the visit as a whole and be able to perform whatever role that was required in that moment. Thus, although all the physicians noted differences in their work routines due to the addition of an EHR and documentation requirements, and physicians in both departments saw scribes as a way for physicians to focus more on the patient, two different perspectives emerged during fieldwork. In Digestive Health, where the requirements of the EHR complicated their work of diagnosing cases, having scribes document patient histories, symptoms, and the physician’s treatment plans allowed the physicians to listen to the patient’s stories and know that important details were being documented. In Ophthalmology, the routine nature of patient cases meant that the addition of a scribe to document information and perform licensed activities such as placing orders freed the physician to focus more on the patient, rather than moving back and forth between the patient in the exam chair and the computer. Despite the substantial differences in routines, physicians in both departments found the scribe role advantageous once a relationship was established. Routines and roles in Ophthalmology When Ophthalmology scribes were paired with physicians, a routine developed fairly quickly as physicians figured out how to best utilize their scribes. Once a routine was established, the physicians often granted an unexpected amount of control to the scribe, which allowed them to act as a buffer between physicians and what they perceived to be non-physician work: ‘a lotta times they [other staff members] will go to the scribe for things before they’ll come to me, because they know I’m busy doing other things’ (Dr Kowalski). Additionally, the type of work also played a part in how much control physicians gave to scribes. For example, Dr Kowalski saw many patients with macular degeneration, which required routine injections. To accommodate the time it took for the eye to numb, Dr Kowalski routinely utilized three or four exam rooms at a time, allowing him to perform an initial exam on a patient and start the numbing process, leave the room to start another patient visit, and then return back to the first patient to perform the injection. Because he saw multiple patients at once, his scribe was not only aware of the patient schedule but also the order in which the physician saw patients. According to Dr Kowalski, Lisa was ‘the paddle to his ping pong ball’, often directing him from room to room. Dr Kowalski was aware of his reliance on Lisa, once joking with the researcher, ‘So that’s going in your notes? “Doctor doesn’t know where to go without his scribe”’ after Lisa stopped him from going into one room and redirected him to another instead. When asked about this observation, Lisa joked, ‘I’m like his work mother. I tell him where to go, what he needs to do next’. In Ophthalmology, where routines developed because of the repetitive nature of the tasks, clarity still took time and seemed to be based on the development of a personal relationship. Ultimately, however, Lisa acknowledged that the division of labor was difficult to describe: ‘There’s only some things that you can teach ahead of time and then it’s gotta be like thrown into it’. Initial observations mirrored this ‘thrown in’ nature, as the researcher observed several times before feeling comfortable with the general flow rather than blindly following the scribe. Indeed, memo notes after the first Ophthalmology shift reflect this, with the researcher noting, ‘Ophthalmology is true chaos from an outsider’s perspective. For both Dr Kowalski and Dr Pappas, the scribe seemed like the one person who knew everything that was going on’. Ophthalmology scribes shared the same access to the EHR as the physicians. Thus, while the note section still needed approval by Ophthalmology physicians, the scribes also had full control over entering and submitting orders. Physicians in Ophthalmology relied on the fact that their scribes were their assistants, which affected the way that scribes blended with the EHR. During an interview, Heather explained her scribe title: ‘since he [Dr. Zayed] switched to using the word assistant rather than scribe or note taker, people get even more comfortable with that. Because that makes sense to them. When you say scribe, not everyone makes the connection’. By referring to scribes as assistants, then, expectations were set for scribes, physicians, and patients about the role the scribe would play in the exam room. Thus, in Ophthalmology, scribes were integrated into the patient care routine. The typical routine involved the scribe entering the room as the physician was preparing to begin the eye exam, with the scribe entrance typically marked by the physician logging out of Epic and turning to the patient in the exam chair. The scribe would then pull out the second stool, sit at the computer, log in, and wait for the physician began the eye exam. It was also common for the scribe to manage the lights during this portion of the patient visit as there was a second switch in most rooms next to the computer; as the physician would lean forward to start the eye exam, the scribe would turn off the overhead lights. As the physician would sit back and begin talking to the patient, the scribe would turn the overhead lights back on. This was routinized to the point where the researcher observed a few times where the physician would talk to the patient in the dark for several seconds while waiting for the scribe to turn the lights on, rather than reach for the lights themselves. After the exam, if the physician wanted to look at a test result or something else in the patient chart, they would indicate to the scribe what they wanted. This might be in the form of, ‘Let’s look at…’ ‘Can we look at [x]?’ or ‘Let me get the note open and then we’ll get started…’—however it was phrased, since the scribe was at the computer, the scribe would navigate to what the physician was asking for. In the case of images, the scribe would often move the window over to the second monitor screen, leaving the patient chart open on the first screen where they would type any findings the physician discussed with the patient. The development of a routine division of labor took time and involved the needs and styles of the scribes as well as those of the physicians. As Afet commented to the researcher as she sat at the computer after a patient left the room, I think generally he [Dr. Pappas] wants me to move onto the next room with him, but sometimes there are things that like I have to get done. Like when they [the patients] go to check out, we have to have something in that box [a required field in the EHR]. So I have to make sure I have something in that box. This comment is a reminder that the EHR constitutes more than an object, but acts as an agent that requires certain behaviors from the scribes and the physicians. This is also a reminder of how the scribes can act as a buffer between the physicians and the EHR, by performing tasks that the physicians no longer thought about by virtue of having someone always taking care of it. Because of the ophthalmology scribes’ ability to document everything and the single computer in the room, it was not necessary for both the physician and the scribe to be in the EHR at the same time. This also meant that it was easier for the physician to physically stay behind or next to the scribe and ask them to move through the EHR if they were looking for something specifically. The researcher observed a few times where the physician would eventually take the mouse from the scribe to scroll to a particular field or window, but only after directing the scribe where to go: Dr. Kowalski standing behind scribe: Look up…uh…back, here, yeah. Ok, so go forward…no, forward. Go here somewhere. Go here. One more. One more. Yeah. August. (at this point he reaches for the mouse; Lisa moves her hand away and lets Dr. Kowalski scroll through the images while remaining seated at the computer). After this process, the physician would turn back toward the patient and continue with the exam, returning total control of the computer back over to the scribe. Because the physician desired that the scribe handle the entire documentation process, it made sense for the scribe to also act as an extension of the physician when it came to other EHR work as well. This avoided constant exchanges in front of the computer; because of the dual role of the scribes, giving them a separate laptop or computer to keep track of would impede their ability to be mobile and respond to the needs of the physician. As such, the lack of separation of tasks and the exam room setup encouraged a similar sharing of work when it came to navigating the EHR. Furthermore, the team-based structure of the department meant that even the researcher, as another body in the room, was often asked to perform simple tasks without hesitation. Although the presence of a researcher and observer was respected, if convenient the researcher was asked to assist with lights, doors, or reminding the scribe of something the physician said. The department assistants also began to treat the researcher as a member of the team, asking about the research, if she knew where the scribe or physician was, if she could pass information on, or if she could move an exam room door flag to save them a walk down the hall. Additionally, ophthalmology patients were also more likely to talk to the researcher, asking about her work or making jokes, indicating that they were used to interacting with multiple people. Thus, we observed a substantial blending of tasks and even cross-functional teamwork among scribes and physicians in Ophthalmology. These types of interactions did not happen in Digestive Health, to which we now turn. Routines and roles in Digestive Health Digestive Health physicians primarily introduced their scribes as ‘helping me with my notes’, (Dr Bukar) with physicians retaining full control over the patient visit. The most assertive behavior observed on the part of scribes in Digestive Health was letting the physician know that the next patient was ready to be seen, ‘when you’re ready’ (Juan). This comment suggests that scribes in Digestive Health perceived greater status differences between themselves and the physicians than scribes in Ophthalmology. It may also be attributable to the fact that digestive health scribes were undergraduate students training for future medical careers, and not already in stable careers, as the OAs maintained. In Digestive Health, physicians typically entered the diagnoses and orders at the end of exams, and sometimes the patient’s instructions, so the physician had recorded everything the front desk needed to check the patient out before the physician left the room. When asked to describe similarities across the physicians they worked with, however, Amelia tried to summarize: For specific illnesses, I know that medical information, so that's the same across the board. …. But as far as small charting differences, I don't think – I don't know any similarities. They're all very different in that aspect. Dr. James and Dr. Yassin do use the same template, but the – What she expects in a chart is different than what he expects. And Dr. Bukar has his own templates. Dr. Caru uses one generic template. And Dr. Shalaby has her own templates as well. Scribes thus stayed with physician from room to room, oftentimes working on multiple patient charts at once. Scribes were frequently observed proofreading a previous patient’s note, while the physician conversed with the current patient about a procedure, possible diagnoses, or personal matters that the scribes felt they did not need to pay attention to. Exceptions arose because of the physicians’ preferences, patient differences, and the idiosyncrasies of the EHR. Thus, while scribes knew that some requested procedures would require a petition to an insurance carrier, or that certain diagnoses meant a specific test, they also knew that each physician preferred a particular documentation style. In contrast to the stability observed in Ophthalmology, scribes in Digestive Health expressed continuing confusion about their roles. Role clarity developed slowly over time, especially in Digestive Health work, according to Yasira: ‘It depends on who you work with’. [Interviewer: So how did you learn that?] Yasira answered, ‘trial and error’. ‘A lot of trial and error’, Amelia added. That's what we say. For a scribe to become proficient or decently good, it takes about three months. …. And I mean, even with Dr. Caru, now that I've worked with him for about six months, I feel like there's still some days where a really odd patient can come in and all of the usual things I'm used to doing, he's like, ‘We're not doing that. This patient wouldn't want it. This patient is this’ (Amelia). Digestive health physicians displayed many more idiosyncrasies about their jobs versus what they expected of their scribes. Questions of interpretation of those roles were continually expressed. For example, some physicians said scribes should not interpret their words, whereas scribes saw their job as interpreting non-technical language into medical terms. While physicians bore ultimate responsibility for the medical notes in the EHR, the point of having a scribe is to alleviate some of that work. However, dividing the work of charting is idiosyncratic both in terms of the department and in terms of individual physicians’ preferences and scribe learning. Working out those roles took time. As Dr James said, My big complaint when the scribes started was, I felt like the note was incredibly immature…And I feel like if a doctor is referring a patient to me, it should be thorough. It should be sophisticated in its nature. They’re asking me my opinion. Dr Shalaby also handwrote notes to herself during patient encounters. She explained that she started doing that with her first scribe: Because it was so messed up. Like with [previous scribe], he felt like he was doing a great job. And he didn’t realize I would spend hours fixing his notes afterward. And then I would get frustrated because I knew how long it was gonna take. And then I would put it off. And then it would just get worse, because it was some time until I got to the note. Then I forgot everything about the encounter. Even though Dr Shalaby commented several times that Yasira’s notes required very little editing, she explained that she kept the practice of handwriting notes during the exam to keep her oriented during her conversation with the patient, as she did not have access to the scribe note while the scribe was working on it. This EHR system does not permit more than one user at a time, and the scribes had separate accounts due to their unlicensed roles; until the scribes submitted their notes for review, the physician was unable to see what the scribe entered. Because this particular physician wanted detailed notes, the scribe typically did not finish while the physician was still with the patient, and instead, the scribe would bounce between multiple notes throughout her shift. The process of wordsmithing notes was very prominent across the digestive health scribes. Yasira would take bullet notes as the patient and physician talked, while Amelia would write one long paragraph. These systems served to capture a basic summary of the patient history as the patient explained their symptoms and answered questions from the physician. Later, these initial jottings would turn into a completed note within the physician template. Because of the level of detail and wordsmithing, it was uncommon for the scribe to complete the note while in the room with the patient. Instead, they would work to capture the information they felt they needed and then begin to edit their notes into the final format. This editing occurred during the patient visit (or a future patient visit) when the scribe felt they could ‘tune out’ the physician–patient conversation, in between patients, or after the physician was done seeing patients for the day. While the scribe worked quietly in the exam room, outside of the exam room it was not uncommon for them to read aloud to themselves as they finalized their work. For example, in the hallway between patient encounters the researcher observed Yasira as she turned her bulleted items into a paragraph and talked to herself as she typed, ‘he admits to feeling…he has also been avoiding dairy products…I’m just going to erase this…in regards to his…’ Some of this wordsmithing process was adapting what the patient said to medical terminology; for example, the researcher watched Yasira type ‘pellets’ when the patient confirmed ‘yes’ to Dr Yassin asking about hard, small bowel movements. But, when the patient later described her pain as ‘ripping’, Yasira typed ‘ripping’ and left it in quotations. Or, when a patient was explaining symptoms of feeling like food does not digest but just sits in her throat, Yasira wrote ‘dysphasia’. In another observation, when a patient was describing their history of stroke and said he was on blood thinners, Amelia wrote ‘due to two strokes, he takes anti-coagulants’. She later scrolled down to the medication list, then deleted ‘anti-coagulants’ and wrote in the prescription name. Knowing when to use medical terminology and when to capture the patient’s exact words seemed to depend on the scribe’s detailed knowledge of physician preferences. Indeed, each physician had a different opinion about the part the scribe should play and the responsibility retained by the physicians. In reference to some of the key features of EHRs, such as access to previous medical records, history of medications, or test results, Dr Bukar specified, ‘I don’t use the scribe to say, ‘look at the past medical history and tell me whether this has been done.’ That is not - I consider that my job’. Regardless of who else worked on the note, at the end of the day the physician bears legal responsibility for the decisions and documentation of patient care. Dr Shalaby, however, expected her scribe to create a summary of each patient prior to the patient encounter. During one observation, after Yasira read her prepared summary to Dr Shalaby, Dr Shalaby turned to the researcher and said: So, Ann. Let me tell you why Yasira is exceptional. What she just said? Let’s break it down. She told me his diagnosis. That’s why he’s here today. She included his recent lab results, so I know what’s been done and what they indicate. She included his platelets, because that’s something I’d want to know when thinking about how to proceed. And she included that he’s 53 and hasn’t had a screening for colonoscopy/upper endoscopy. That has nothing to do with his visit, but she knows we start screening at 50, so it’s good to know. She covers the whole patient, which other scribes don’t do. Even the people before her, they thought they knew more than me. I’d talk treatment plan, they’d have something totally different. She’s exceptional, and we’re basically trying to create clones of her! In contrast to Dr Bukar, then, who considered looking at a patient’s medical history his job, Dr Shalaby preferred her scribe to summarize the whole patient. The first part of satisfying Dr Shalaby’s preference was identifying why the patient was there that day; sometimes, this information was easy to find, but other times, the referral was buried in the patient’s chart or there were technical issues. Yasira once expressed frustration at not being able to tell why the patient was there and then later clarified for the researcher, ‘I found it. It had stopped loading at June. That’s Epic’. Even if Yasira was able to quickly find the correct documentation that identified why the patient was there, her ability to easily understand how to translate that into a summary for the physician depended on the quality of the documentation she was looking at. For example, while working on preparing charts prior to seeing patients one day Yasira commented to the researcher that she was reading the best Emergency Room summary she’s ever seen. She explained that emergency visits and discharge statements ‘usually suck’ as they use abbreviations that she does not know or are very brief, but this one was full of information. Finding previous lab or test results could also be difficult; during one observation day, Yasira frustratingly commented that there should be a job just for converting scanned documents into the patient history. That day she was preparing patient charts for a lot of new patients, which meant that their history was scanned in from other providers. However, there was no standardized process for naming these scanned documents, meaning she was having to open documents with random titles to find the information she was looking for. This process also involved knowing information the physician would want based on the diagnosis; for example, if a patient had been diagnosed with GERD, she knew to include information from any previous chest X-rays or procedures that involved the esophagus/chest area of the body. This demonstrated knowledge not only of physician preference, but also medical information in connecting diagnosis with procedures in the EHR. Thus, in addition to revealing the work Yasira did for Dr. Shalaby specifically, this incident reveals the detailed knowledge Yasira had of the EHR and her role in translating its information. DISCUSSION The purpose of this study was to explore the negotiated order of the professional work of physicians and medical scribes that emerged from the imposition of a technology—EHRs. Since 2009 in the USA, the mandated use of EHRs requires physicians to engage with a technology in addition to their traditional routines. Investigating both Ophthalmology and Digestive Health departments in a US hospital, we found that work routines were fundamentally different across different areas of practice. Thus, previous studies looking at scribe efficiency without acknowledging different work routines missed a key component of the scribing role, adapting to the routines in different specialty areas. Furthermore, quantifying scribes in terms of efficiency without considering the relationships between physicians and scribes ignores the importance of the connection between a physician and scribe and their negotiated roles. Physicians in both departments we observed were able to articulate general ideas about what they found most helpful from a scribe, but further observations and conversations with scribes demonstrated that scribes were learning and sharing nuances that physicians did not explicitly convey. Therefore, researchers who want to study a professional role should also consider the work routines of individual professional workers, as those roles are ultimately founded on idiosyncratic routines. Focusing on the nature of the roles and routines shared by scribes and physicians, we found that discarded professional tasks may end up in an unregulated space. Although some occupations emerge and stabilize to formally pick up those tasks, the unregulated nature of scribing in the USA means that their activity is not cleanly segmented from that of physicians. As our fieldwork shows, even physicians within the same specialty have different expectations of their scribes. Thus, not only is scribing negotiated generally at the level of daily activities, but also between each physician–scribe pair. As control over scribes’ work was left up to physicians, we see differing levels of separation of tasks across physicians and scribes. That is why we call this professional fissure: a space in which tasks are cleaved from a profession, but not completely separated. Medical scribes are an example an occupation emerging from professional fissure. It was scribes’ independent interaction with EHRs that generated a measure of agency upon which some of our physician participants relied. Our data hint that scribing may become a stable role or function within Ophthalmology due to the interactive nature of the work and the willingness of the physicians to share tasks within the larger routine. Digestive health physicians, however, are used to working independently, and future generations may become comfortable incorporating EHR requirements into their regular work routines, meaning the benefits of a scribe may not last. Connecting work routines to roles may tell us what roles are likely to last, and what roles may be more transitionary as a professional practice adjusts to changes like the imposition of the EHR. This is especially true when considering the addition of new technologies; as Dr Caru mentioned, a stethoscope was once seen as a major shift in physician work, whereas today it is seen as a symbol of the profession. Evetts (2011) noted that, for the most part, professionalism is imposed from above by employers and managers within organizations. In our case, however, the imposition came from federal policy and was directed at physician behavior. Since many US physicians now find themselves attached to organizations, organizations find themselves in a position to balance federal policy, their own managerial interests, and the roles of professionals. The ideology of professionalism is a powerful incentive to new and existing occupational groups, but the unique nature of institutional imposition is not fully captured in work on professionals. Indeed, as our case shows, rather than organizational objectives defining practitioner–client relations, or setting achievement targets and performance indicators, federal policy sets these standards (Evetts 2011). As such, while organizations have thus been thought of as replacing occupational control, our case shows how constraints imposed from outside the organization may in fact interfere with professional control while simultaneously causing fissures in the profession. The story of scribes and physicians is relevant to larger issues in studies of emerging and changing professions. First, scribes, in addition to physicians and others, inhabit the institution of health care. The emergence of the scribe role reflects changes in the roles of physicians as well as the broader institution of healthcare which they inhabit (Hallett and Ventresca 2006; Alvehus, Eklund and Kastberg 2019). Concerns about cost and quality are challenging the traditional dominance of the medical profession. Clearly, inhabitation involves negotiation. Second, therefore, while the role of the scribes is negotiated with physicians, we noticed that that negotiation is situation specific. Ambiguities in the conduct of physicians’ roles mean that each scribe’s role depends upon not only a particular physician but also the physician’s type of practice (Reed and Thomas 2019). Also, the negotiation itself arises because of the external imposition of EHRs by the federal government. The fissure we observed in the professional role might be observed in other professions such as the teachers studied by Alvehus, Eklund and Kastberg (2019), the architects studied by Bos-de Vos, Lieftink and Lauche (2019), or the accountants studied by Bévort and Suddaby (2016). One limitation of our study is that our access was limited to two departments within one hospital. In much the same way research findings on efficiency differ across specialties, we would expect the roles and routines of scribes to differ across settings, much like we see in our two cases. A second limitation of our study is the lack of data at the managerial and organizational levels. Because our focus was on the day-to-day activities of physicians and scribes, we did not capture macro-decisions that impacted the work we observed. Future studies would do well to consider the influence of organizational and managerial perspectives in addition to daily routines. Furthermore, our study did not focus on the aspects of professionalism such as gender differences, although medical scribes may be an interesting site for future research. As Evetts (2011) noted, more women are entering established professions, men are entering female professions, and traditionally female-dominant occupational positions have utilized professionalism to secure new tasks, responsibilities, and recognition. Within our small study sample, medical scribes were either connected to pre-established, female-dominate occupations such as medical assistants, or viewed as a stepping-stone to a medical career. Though the majority of our scribe participants were female, future research may show gender differences between the medical scribe role attached to pre-existing gendered roles and the medical scribe experience as a stepping-stone into a medical career. CONCLUSION In conclusion, we set out to understand how the external pressure of a new technology and the resulting emergence of a new occupation influenced professional work. In our case, the mandated use of EHRs created a fissure in physicians’ work through the addition of tasks inconsistent with traditional notions of medical practice. Though prior studies have focused on efficiency and productivity related to the addition of medical scribes, our study demonstrates that physician workflow influences the selection of a scribe staffing model. Indeed, fissure in Ophthalmologists’ work was handled through the incorporation of scribing tasks to an already existing role, leading to increased teamwork. Alternatively, fissure in Digestive Health physicians’ work created nuanced articulations of what the role of the physician versus the scribe should be. Thus, although medical scribes are considered an emerging occupation based on stenography, we see significant differences across medical specialties and individual physicians regarding the role of medical scribing. These differences have serious implications for the future of the medical profession, as physicians decide whether and how much control to yield to scribes. Professional fission also has implications for professions at large; when there is mandated external pressure on a profession, alterations of work may be expected to occur. Professionals are not monolithic, they do not work independently from other occupations, and they are subject to external forces, all of which generate new forms of interaction. In these interactions, we can find new roles and routines that emerge, with the expectation that these new roles will acquire expertise and agency. Understanding these roles, we argue, requires a close look at the routines that accompany them. Taking an ethnographic approach to the intersection of institutional pressure, occupations as negotiated orders, variation in work practices within organizations, and profession thus showcase how messy and ambiguous the rise of an occupation that emerges out of professional fissure can be. Funding This research was supported by grant RB16035, funded by the University of Illinois Research Board. REFERENCES Abbott A. ( 1988 ). The System of Professions: An Essay on the Division of Expert Labor . Chicago : University of Chicago Press . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Alvehus J. Eklund S. Kastberg G. ( 2019 ) ‘ Inhabiting Institutions: Shaping the First Teacher Role in Swedish Schools ’, Journal of Professions and Organizations , 6 / 1 : 33 – 48 . Google Scholar Crossref Search ADS WorldCat Anonymous . ( 2014 ). The disturbing confessions of a medical scribe. Medpagetoday’s KevinMD.com <https://www.kevinmd.com/blog/2014/03/confessions-medical-scribe.html> accessed 23 Sept 2020. Arya R. , Salovich D. M., Ohman-Strickland P., and Merlin M. A. et al. ( 2010 ) ‘ Impact of Scribes on Performance Indicators in the Emergency Department ’, Academic Emergency Medicine , 17 / 5 : 490 – 4944 . Google Scholar Crossref Search ADS PubMed WorldCat Barrett A. K. ( 2018 ) ‘ Electronic Health Record (EHR) Organizational Change: Explaining Resistance through Profession, Organizational Experience, and EHR Communication Quality ’, Health Communication , 33 / 4 : 496 – 506 . Google Scholar Crossref Search ADS PubMed WorldCat Barrett A. K. Stephens K. K. ( 2017 ) ‘ Making Electronic Health Records (EHRs) Work: Informal Talk and Workarounds in Healthcare Organizations ’, Health Communication , 32 / 8 : 1004 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat Bechky B. A. ( 2011 ) ‘ Making Organizational Theory Work: Institutions, Occupations, and Negotiated Orders ’, Organization Science , 22 / 5 : 1157 – 67 . Google Scholar Crossref Search ADS WorldCat Berg M. ( 1996 ) ‘ Practices of Reading and Writing: The Constitutive Role of the Patient Record in Medical Work ’, Sociology of Health and Illness , 18 / 4 : 499 – 524 . Google Scholar Crossref Search ADS WorldCat Berg M. ( 1999 ) ‘ Patient Care Information Systems and Health Care Work: A Sociotechnical Approach ’, International Journal of Medical Informatics , 55 / 2 : 87 – 101 . Google Scholar Crossref Search ADS PubMed WorldCat Bévort F. Suddaby R. ( 2016 ) ‘ Scripting Professional Identities: How Individuals Make Sense of Contradictory Institutional Logics ’, Journal of Professions and Organization , 3 / 1 : 17 – 38 . Google Scholar Crossref Search ADS WorldCat Blumenthal D. ( 2010 ) ‘ Launching HITECH ’, New England Journal of Medicine , 362 / 5 : 382 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat Bodenheimer T. Willard-Grace R. Ghorob A. ( 2014 ) ‘ Expanding the Roles of Medical Assistants: Who Does What in Primary Care? ’, Journal of the American Medical Association Internal Medicine , 174 / 7 : 1025 – 6 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Bos-de Vos M. Lieftink B. M. Lauche K. ( 2019 ) ‘ How to Claim What is Mine: Negotiating Professional Roles in Inter-Organizational Projects ’, Journal of Professions and Organization , 6 / 2 : 128 – 55 . Google Scholar Crossref Search ADS WorldCat Bossen C. Chen Y. Pine K. H. ( 2019 ) ‘ The Emergence of New Data Work Occupations in Healthcare: The Case of Medical Scribes ’, International Journal of Medical Informatics , 123 : 76 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat Bryant A. D. Fletcher G. S. Payne T. H. ( 2014 ) ‘ Drug Interaction Alert Override Rates in the Meaningful Use Era: No Evidence of Progress ’, Applied Clinical Informatics , 5 / 3 : 802 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat Bucher R. Strauss A. ( 1961 ) ‘ Professions in Process ’, American Journal of Sociology , 66 / 4 : 325 – 34 . Google Scholar Crossref Search ADS WorldCat Cheney G. Ashcraft K. L. ( 2007 ) ‘ Considering “the Professional” in Communication Studies: Implications for Theory and Research within and beyond the Boundaries of Organizational Communication ’, Communication Theory , 17 / 2 : 146 – 75 . Google Scholar Crossref Search ADS WorldCat Dingwall R. ( 1983 ) ‘ In the Beginning Was the Work:” Reflections on the Genesis of Occupations ’, The Sociological Review , 31 / 4 : 605 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat Evetts J. ( 2003 ) ‘ The Construction of Professionalism in New and Existing Occupational Contexts: Promoting and Facilitating Occupational Change ’, International Journal of Sociology and Social Policy , 23 / 4/5 : 22 – 35 . Google Scholar Crossref Search ADS WorldCat Evetts J. ( 2011 ) ‘ A New Professionalism? Challenges and Opportunities ’, Current Sociology , 59 / 4 : 406 – 22 . Google Scholar Crossref Search ADS WorldCat Evetts J. ( 2013 ) ‘ Professionalism: Value and Ideology ’, Current Sociology Review , 61 / 5–6 : 778 – 96 . Google Scholar Crossref Search ADS WorldCat Frankel R. ( 2016 ) ‘ Computers in the Examination Room ’, JAMA Internal Medicine , 176 / 1 : 128 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat Gellert G. A. Ramirez R. Webster S. L. ( 2015 ) ‘ The Rise of the Medical Scribe Industry Implications for the Advancement of Electronic Health Records ’, Journal of the American Medical Association , 313 / 13 : 1315 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat Gioia D. A. Corley K. G. Hamilton A. L. ( 2013 ) ‘ Seeking Qualitative Rigor in Inductive Research: Notes on the Gioia Methodology ’, Organizational Research Methods , 16 / 1 : 15 – 31 . Google Scholar Crossref Search ADS WorldCat Hafner K. ( 2014 , January 12). A busy doctor’s right hand, ever ready to type. The New York Times. <http://www.nytimes.com/2014/01/14/health/a-busy-doctors-right-hand-ever-ready-to-type.html> last accessed 23 Sept 2020. Håland E. ( 2012 ) ‘ Introducing the Electronic Patient Record (EPR) in a Hospital Setting: Boundary Work and Shifting Constructions of Professional Identities ’, Sociology of Health & Illness , 34 / 5 : 761 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat Hallett T. Ventresca M. J. ( 2006 ) ‘ Inhabited Institutions: Social Interactions and Organizational Forms in Gouldner’s Patterns of Industrial Bureaucracy ’, Theory and Society , 35 / 2 : 213 – 36 . Google Scholar Crossref Search ADS WorldCat Healthit.gov . ( 2013 ). What is an Electronic Health Record? [website]. <https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr> last accessed 23 Sept 2020. Hess J. , Wallenstein J., Ackerman J., Akhter M., Ander D., Keadey M., and Capes J. et al. ( 2015 ) ‘ Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice ’, Western Journal of Emergency Medicine , 16 / 5 : 602 – 10 . Google Scholar Crossref Search ADS PubMed WorldCat Hughes E. ( 1993 ). The Sociological Eye . London : Transaction . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Kayden S. , Anderson P. D., Freitas R., and Platz E. et al. ( 2014 ). Emergency Department Leadership and Management: Best Principles and Practice . Cambridge : Cambridge University Press . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Kessler I. Heron P. Dopson S. ( 2015 ) ‘ Professionalization and Expertise in Care Work: The Hoarding and Discarding of Tasks in Nursing ’, Human Resource Management , 54 / 5 : 737 – 52 . Google Scholar Crossref Search ADS WorldCat Koshy S. et al. ( 2010 ) ‘ Scribes in an Ambulatory Urology Practice: Patient and Physician Satisfaction ’, Journal of Urology , 184 / 1 : 258 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat Lammers J. C. , Lambert N. J., Abendschein B., Reynolds-Tylus T., and Varava K. et al. ( 2016 ). ‘Expertise in Context: Interaction in the Doctors’ Room of an Emergency Department’, in Leonardi P. and Treem J. (eds) Expertise, Communication, and Organizing . Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Liu S. ( 2018 ) ‘ Boundaries and Professions: Toward a Processual Theory of Action ’, Journal of Professions and Organizations , 5 / 1 : 45 – 57 . Google Scholar Crossref Search ADS WorldCat Morrison Z. , Fernando B., Kalra D., Cresswell K., and Sheikh A. et al. ( 2014 ) ‘ National Evaluation of the Benefits and Risks of Greater Structuring and Coding of the Electronic Health Record: Exploratory Qualitative Investigation ’, Journal of the American Medical Informatics Association , 21 / 3 : 492 – 500 . Google Scholar Crossref Search ADS PubMed WorldCat Murphy R. ( 1988 ). Social Closure: The Theory of Monopolization and Exclusion . Oxford : Clarendon Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Noordegraaf M. ( 2007 ) ‘ From “Pure” to “Hybrid” Professionalism: Present-Day Professionalism in Ambiguous Public Domains ’, Administration & Society , 39 / 6 : 761 – 85 . Google Scholar Crossref Search ADS WorldCat Noordegraaf M. ( 2015 ) ‘ Hybrid Professionalism and beyond: (New) Forms of Public Professionalism in Changing Organizational and Societal Contexts ’, Journal of Professions and Organizations , 2 / 2 : 187 – 206 . Google Scholar Crossref Search ADS WorldCat Office of the National Coordinator for Health Information Technology . ( 2019 , January). Office-based physician electronic health record adoption: Health IT quick-stat #50. <https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php> last accessed 23 Sept 2020. Office of the National Coordinator for Health Information Technology . ( 2017 , September). Non-federal acute care hospital electronic health record adoption: Health IT Quick-Stat #47. <dashboard.healthit.gov/quickstats/pages/FIG-Hospital-EHR-Adoption.php> last accessed 23 Sept 2020. Orr J. E. ( 2016 ). Talking about Machines: An Ethnography of a Modern Job . Ithaca, NY : Cornell University Press . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Poissant L. , Kittler A. F., and Volk L. A. et al. ( 2005 ) ‘ The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review ’, American Medical Informatics Association , 12 / 5 : 505 – 16 . Google Scholar Crossref Search ADS WorldCat Proulx J. Bryan A. L. Lammers J. C. ( 2016 , November). The Communicative Production of Institutional Force: Policy Discussions and Electronic Health Records. Annual Meetings of the National Communication Association. Philadelphia, PA. Reed C. Thomas R. ( 2019 ) ‘ Embracing Indeterminancy: On Being a Liminal Professional ’, British Journal of Management , 00 : 1 – 16 . Google Scholar OpenURL Placeholder Text WorldCat Rutten L. J. et al. ( 2014 ) ‘ Enabling Patient-Centered Communication and Care through Health Information Technology ’, Journal of Communication in Healthcare , 7 / 4 : 255 – 61 . Google Scholar Crossref Search ADS WorldCat Santiago A. C. (n.d.). Medical scribes - Career overview: Medical scribes aim to improve physicians' communication. <http://healthcareers.about.com/od/healthcareerprofiles/fl/Medical-Scribes-Career-Overview.htm> last accessed 23 Sept 2020. Shultz C. G. Holmstrom H. L. ( 2015 ) ‘ The Use of Medical Scribes in Health Care Settings: A Systematic Review and Future Directions ’, Journal of American Board of Family Medicine , 28 / 3 : 371 – 81 . Google Scholar Crossref Search ADS WorldCat Strauss A. Corbin J. ( 1990 ). Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA : Sage . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Strauss A. , Schatzman L., Ehrlich D., Bucher R., and Sabshin M. et al. ( 1963 ). ‘The Hospital and Its Negotiated Order’, in Freidson Eliot (eds.) The Hospital in Modern Society , pp. 147 – 169 . New York: The Free Press. Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC The Joint Commission . ( 2019 ). Standards FAQ Details. <https://www.jointcommission.org/standards_information/jcfaqdetails.aspx? StandardsFaqId=1908& ProgramId=46> accessed 25 Oct 2019. Wenger R. G. ( 2015 ) ‘ Letter from the Chair: Medical Scribes Increasing ’, Forum: News of the American Society for Healthcare Risk Management , 3 : 1 – 9 . Google Scholar OpenURL Placeholder Text WorldCat Woodcock D. V. , Pranaat R., McGrath K., and Ash J. S. et al. ( 2017 ) ‘ The Evolving Role of Medical Scribe: Variation and Implications for Organizational Effectiveness and Safety ’, Studies in Health Technology and Informatics , 234 : 382 – 8 . Google Scholar PubMed OpenURL Placeholder Text WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Professional fission in medical routines: medical scribes and physicians in two US hospital departments
JF - Journal of Professions and Organization
DO - 10.1093/jpo/joaa023
DA - 2020-10-02
UR - https://www.deepdyve.com/lp/oxford-university-press/professional-fission-in-medical-routines-medical-scribes-and-CiwP9ijpyC
SP - 1
EP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -