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The World of Medical Transcription From a Medical Language
Specialist Point of View
As a certified medical transcriptionist who has become rather exophytic to the classic
definition of such, I have been asked to write a column on what medical transcription is
today, what it has meant to me, and what medical transcriptionists need. To me, the
question is, What do we need to not only survive the day, but embrace the day?
Of course, a medical transcriptionist (MT) in the purest form of the definition takes verbal
dictation (sometimes supplemented with written notes) and by magic with one million
variables, turns voice into a magnificent printed patient chart note, accurate and clear,
encompassing the highest standards of accuracy in medicine, English, grammar and syntax.
In this discussion I will point out that the pursuit of excellence and embracing change
are the two most-needed characteristics for medical transcriptionists today. We must
evolve (and are evolving) into medical language specialists, medical word editors, team
players, technologists, and diction experts for English-as-a-second-language authors. Ill
try to give you some ideas from a multifaceted approach, and perhaps enclose a little
humor, as well, because I believe that taking a lighthearted but sure approach and keeping
perspective is good for the soul.
AAMT and MTIA and other organizations are wonderful resources for industry ideas relating
specifically to medical transcription. For example, the Journal for the American Association
for Medical Transcription (JAAMT) has hundreds of wonderful articles on what exactly
transcription is, where it is headed, the impact of overseas transcription on the United
States, newest technologies, and other deliberations. I encourage you to join these
organizations. I wont belabor those ideas here, but rather lets briefly discuss some broad-
based health industry ideas and show how those relate to a medical word
editor/transcriptionist as part of a team. As medical language specialists, we can elect
to operate in more than one area of the modern- day healthcare team using our
medical language skills. These topics are my favorites.
At the end, I will leave you with my 15 top tips as a medical transcription educator.

A Beginning

I had a humble inception to the medical world. I became the radiology department
receptionist for our community hospital at the tender age of 21 years of age. A lot of
harried physicians looking for that last-minute x-ray disrupted my ataraxy. One day, I
glanced back at the radiology transcriptionist partially hidden from view behind a cornucopia
of x-ray files. At that moment, I had missing plain films for a patient on a table in the OR, a
doctor needing a courier to bring an x-ray across the street for a patient in treatment, and a
resident physician asking for a chest x-ray for an acutely ill patient in ICU. But, there she
was in the back, ears in, small turned up edges on her lips, (I know I saw the blithe
smile!), transcribing away, oblivious to chaos. Or at least pretending to be oblivious to
chaos. Given that her pay scale was higher than mine, as well, I made a pledge to myself
that I would learn all about that peaceful job in the back corner. Medical Transcription.
And I did. Every break and lunch hour for four (my goodness, should that be the numeral


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4!) months I would sit in the honored seat and practice those radiology reports. She would
proofread what I did upon her return and gave great feedback. (A formula for success:
transcription, receiving feedback, accepting feedback, and trying again.) Then one day, the
skilled transcriptionist called in sick; I was asked to transcribe, and I said yesah, the
beginning.

I realized education and knowledge are the keys to this interesting world of words and
grammar. The hospital gave me keyboarding, medical terminology, and anatomy and
physiology at the community college. Galvanic words packed my life, a profusion of them
(now, thats not perfusion). I earned my associates degree and began working on a
bachelors. My quest for intoxicating new words and knowledge soon found me transcribing
ultrasound and radiation therapy reports downstairs at the end of my shift. An exciting new
venture! What IS that word?

A humorous side note:

A medical societys contribution I once read best describes that myelination process in my
brains grey matter at that time; there were words everywhere! A chrysalis process
developed with seemingly innocuous words:

The obituary gland seems a sad place to start? Moving down the ophagus tube, past the
broccoli, a fundoapplication may help. You may recognize the psychiatric nerve, but what
about the haricot veins? The introverted uterus is a little shy, but the crucial ligaments are
obviously important. Platinums and playtex are everywhere.
(Pituitary gland, esophagus, bronchi, fundoplication, sciatic nerve, varicose veins,
retroverted uterus, cruciate ligaments, platelets.)

Having sorted out the anatomy, the various ailments were next. There are many inflations
in the vocabulary. Does the human Pavarotti virus affect the vocal chords? What organs are
involved with a hippopotamus or a helicopter, and what causes the sinkable episode?
(Inflammations, human papillomavirus, hypothalamus, Helicobacter, syncopal)

For the surgeons, I need help with the biblical hernias and erupted spleen. It may be a little
more difficult to decide which specialist to refer a fractured zygote, a utopic pregnancy,
bunyips, painful anodes and the occasional Arnold Curarie.
(Umbilical hernias, ruptured spleen, fractured zygoma, ectopic pregnancy, bunions, nodes,
Arnold Chiari malformation.)

We could probably send the pigsty, cellutosis, cradle crop, scarytosis, and ectopic eczema to
the dermatologists (if they are not at a conference in Barcelona or Melanesia), but who
treats those septic ulcers?
(Stye, cellulitis, cradle cap, solar keratosis, atopic eczema, basal cell carcinoma, melanoma,
peptic ulcers.)

The respiratory physicians, with their stereophone moved from sleep apathy to bronchial
ecstasy, but should postnatal drips and reproductive coughs go to them or the
obstetricians? Even more confusing are Alka Seltzer's disease, tetanus and tendonitis, which
are not what they seem. The physicians could investigate grout,


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osteoferocious and facetious anaemia and handle a myocardial infraction. And for the
lawyers is needless dysplastic syndrome considered as incompetence or a minuscule
tear?
(Stethoscope, sleep apnea, bronchiectasis, postnasal drip, productive cough, Alzheimer's
disease, tinnitus, gout, osteoporosis, pernicious anemia, myocardial infarction, dysplastic
nevus, incontinence, meniscal tear.)

Then there are the things that doctors do to patients which make one wonder about
transcribing informed consent. If you seduced the patient into a colossal story what would
you expect? A tubal litigation may follow, or perhaps swifter justice with a lumbar punch.
Monograms and egg, lettuce and fried tomatoes are common investigations, but who wants
the Geiger counter or MI5? If the patient asked for the locum, or, worse still, for the results
of their own autopsy, how would you respond? They may be better going to the
physioterrorist, or just to the choir practice.
(Induced, colostomy, tubal ligation, lumbar puncture, mammogram, E/LFT's, glucometer,
MRI, local anaesthetic, biopsy, physiotherapist, chiropractor.)

But the best mispronunciations of all are the muddled medications. The metropolis tablets
are real blocker beaters, and others prefer the condominium lifestyle, but on a bad day it
may be necessary to retreat to Nimbin for a bit of peace and quiet. We could go there in the
Valiant, filling up with Caltex on the way, but hopefully avoiding an argument when the map
reading leads us astray.
(Metoprolol, beta blockers, Coumadin, Nemdyn ointment, Valium, Caltrate, Augmentin.)

The medical profession has all sorts of alternative remedies, for Anzacs and aristocrats and
perhaps even the odd pessowary. These include marzipan, genetic tablets and those well-
known urinal tablets, and Laminex, but there is less demand for the repulsive tablets.
(Zantac, Aristocort, pessary, temazepam, generic, Ural, Lasix, Propulsid.)

On that note, now that you are completely confused by trying to be bilingual, get out the
Kleenex, sit back and hope it all goes into remittance.
(Nitrolingual, Keflex, remission.)

Working from a Home Office

I began to ask physicians receptionists calling in to radiology if they needed any help with
transcription. I soon landed two private practice physicians to transcribe in my spare time
in the evenings at home. From there, I had my second child and garnered other accounts,
starting my own transcription service from home, building a home office, and loaning myself
out per diem to the hospitals. I began to be less passive in my transcription and more
pro-active, less verbatim and more into risk management for documented patient
information. Clients appreciated the attention to detail, mg and mEq dosing flags, and a left
out plan or assessment item.

American Association of Medical Transcription (AAMT)

This wonderful organization came into view, and I joined the local chapter. In an
inordinately short period of time I became president (Im sure by default -- I think I was set
up, honestly.) However, it was here that I was introduced to a Certified Medical
Transcriptionist (CMT) who had a quest and a love for words. The walking encyclopedia


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was her unofficial title (if you are reading this article, Gail, you know who you are!) Wow, a
mentor! One day, I transcribed overflow for her office and found my well-perused and
labored-over documents returned punctuated (thats not punctated!) in red marks. Ah,
seems I knew the words, but not the syntax, language structure, and grammar rules to
provide the polish. I tucked my head down and poured over a new book, the American
Association of Medical Transcription Book of Style. I took the new rules, which I was
cognizant were clearly in place for reasons I could not have had the opportunity to figure
out for myself, the Style garnered from errors made in patient records that I was not privy
to; and I realized it was a gold mine of professionalism.

You see, a medical transcriptionist is part of large team. We do a lot more than drop words
verbatim onto paper. Physicians, nurses, and even medical coders rely on our accuracy and
knowledge of these rules. With skill, the transcriptionist reduces errors in healthcare and
participates in risk management. I took the AAMT exam and became a Certified Medical
Transcriptionist. Someone once said (now, I dont CLAIM its true but it FEELS like it) that
it takes the head knowledge of a resident physician to pass the CMT exam. It is no easy
task.

Lets discuss a couple health industry ideas that really impressed me reading industry-
wide journals and taking college courses in principles of management. Then, well discuss
more of these later.

The Onion Model and the Swiss Cheese Model

You see, the Onion Model illustrates variables that affect the multiple levels of a tiered
system in which a task is performed and errors can occur -- like layers being peeled from an
onion. In transcription, the system is patient healthcare and we help provide the
documentation layer. A fellow named James Reason also developed the "Swiss Cheese
Model" to illustrate how analyses of major accidents and catastrophic systems failures tend
to reveal multiple, smaller failures leading up to an actual negative event. In his model,
each slice of cheese represents a safety barrier or precaution relevant to a particular
hazard. For example, if the hazard were wrong-site surgery, slices of the cheese might
include conventions for identifying sidedness on radiology tests, a protocol for signing the
correct site when the surgeon and patient first meet, and a second protocol for reviewing
the medical record patient notes and checking the previously marked site in the operating
room. Many more layers exist, including the medical transcription layer, I might add, where
lefts and rights are always verified during transcription. The point is that no single barrier is
foolproof. They each have "holes"; hence, the Swiss Cheese Model or layers as in the
Onion Model. For some serious events (e.g., operating on the wrong site or wrong person),
even though those holes will align infrequently, even rare cases of harm (errors making it
"through the cheese") will be unacceptable.

The transcriptionist is part of the team providing accurate and as perfect healthcare as
possible. Well discuss more about some of these industry ideas later.

Educating Others

Friends began to approach me to help them become transcriptionists. I worked with them
and employed the most promising to help with my accounts. My transcription service grew
as I watched the leading edge of technology. We originally started on IBM Selectrics in


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radiology (ha ha) and moved to memory typewriters and on to personal PCs. Then, I had
the opportunity to set up and administrate a VDI voice system for a new family practice
residency. It was there I was approached about teaching dictation 101 to the resident
physicians, which I did. Now that was fulfilling, catching those authors before they began a
lifetime of iniquitous dictation.

A Derailing Accident

I personally was literally derailed at this point by an Amtrak wreck, which caused punctate
hemorrhage in my brain, affecting word-retrieval abilities and partial complex seizures.
Word retrieval returned relatively quickly, but subseizure activity in the brain kept me on
medication that affected my edge and ability to both care for family and job, as well. I
had to leave the profession. Slowly, most all resolved and I was able to pick up where I left
off, starting carefully with a couple of small physical therapy accounts, which I felt were
easier and not too demanding. My lesson learned: Hang in there!

Educating Some More

As a people person, I continued to find education and contact with others the most
fulfilling. I began to teach medical terminology for a local personnel and training company a
couple of years later. I began to realize, as many transcriptionists do, that there are
opportunities out there that employ medical language specialists; hitting the keyboard all
day is not for all. For some, straight transcription is all that is needed and wanted; for
others, it is not. Soon the terminology students clamored for a medical transcription class,
and so it began.

Electronic Medical Records

Soon after that, I answered an ad on the AAMT board for a small part-time position for a
medical transcriptionist to train physicians on the use of an electronic medical record. Ha,
that little part-time job soon took over my life. I connected remotely computer-to-computer
to physicians all over the United States and trained them how to use their new electronic
medical record (EMR). I learned more about connections and firewalls than about EMRs!
My job as an MT was to help providers build their medical knowledge databases that could
be dropped in to patient notes to supplement their transcription. Soon I was going on site
to these offices all over the United States, and my dream was fulfilled to be able to use
medical language and transcription skills and still be in an environs of people. For seven
years I worked with this electronic medical record, using a knowledge of words and
medicine to take what physicians gave me and constructing it into their personal medical
knowledge databases. I attended many trade shows and studied other applications.

Through these contacts and networking, I connected with persons developing web
applications and helped write medical technical manuals for new medical software and web
applications on occasion.

QA and Training Supervisor

Recently, I took a position as QA and training supervisor for a large multihospital heath
system. This proved to be a difficult adjustment because for the first time I could see
clearly what impacted quality, production, and morale, but had little say in what happened


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in this, and limited ability to introduce the successful ways from private practice client-
centered business into a large corporate world. The point is, if the glove doesnt fit, find
your glove! Dont be afraid to try that position that challenges you, teaches you, and moves
you to your highest level of competency (my best advice). With that, if you find you
dont thrive, it will help you understand where you do thrive.

As I took you through this glimpse into one transcriptionists incursion into the world of
grammar, syntax, words, and yes people -- I hope that you feel you can broaden your own
horizon. Every person is not going to have the same visionbut we all need the same
vision of striving for excellence. As technology aids us in our quest for more and better
communication in patient information, our positions will change. We all need to not only
ride the wave of technology but embrace the technology and the pursuit of superlatives in
our profession. Todays medical transcriptionist needs to be a medical word editor,
an English-as-a-second language specialist, a technology advocate, and a pursuer
of latest terminology and ideas, all within the context of a team.

Discussing Health Industry Ideas
AAMT and MTIA are wonderful resources for industry ideas relating specifically to
transcription, as stated above. Wonderful articles are written, and I encourage you to read
some of those. Here, lets briefly discuss some broad-based health industry ideas that
become specific to medical language specialists.
Health literacy is an individuals ability to find, process, and comprehend the basic health
information necessary to act on medical instructions and make decisions about their health.
In classes, students and I discussed that medical terminology and an understanding of
disease processes enhances your life. This knowledge helps you make more informed
choices about your healthcare and the healthcare of ones you love. (Its not just about
medical transcription or medical word editing.)
I took my own mother through Virginia Mason Clinic in Seattle as she died of metastatic
lung cancer, and was able to help her make informed choices -- health literacy. If you
have children, youll be more knowledgeable in your childrens healthcare. You see, it spills
over into life. Which came first, the chicken or the egg? The love of knowledge and
medical words, or did exposure to medical words teach us to love the knowledge?

Patient Safety Networks Healthcare Research and Quality

Today, medical language specialists and medical word editors think in terms of risk
management. We are part of a whole team providing care to patients. I am reminded of
a verse in the New Testament, if I may:

For in fact the body is not one member but many. If the foot should say, "Because I am not a hand, I am not of the
body," is it therefore not of the body? And if the ear should say, "Because I am not an eye, I am not of the body," is it
therefore not of the body? If the whole body were an eye, where would be the hearing? If the whole were hearing,
where would be the smelling?... But now indeed there are many members, yet one body.

Borrowing this biblical principle to medical language specialists, we are an important
member of the body, the team, and we need to see ourselves as such. When we manage
ourselves in a way that promotes excellence, including becoming certified medical


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transcriptionists, constantly increasing our knowledge, we promote professionalism for
our field. (Why shouldnt two separate numbers be transcribed as numerals together?) We
take advantage of knowledge and professionalism that would have never come into our own
limited view by borrowing from professional organizations such as the American Association
for Medical Transcription and the American Medical Association. We participate in risk
management by way of using the latest materials and resources available.
Crew resource management (CRM), also called crisis resource management in some
contexts (eg, anesthesia), encompasses a range of approaches to training groups to
function as teams, rather than as collections of individuals. Originally developed in aviation,
CRM emphasizes the role of "human factors"-the effects of fatigue, expected or predictable
perceptual errors (such as misreading monitors or mishearing dictation), as well as the
impact of different management styles and organizational cultures in high-stress, high-risk
environments. A culture of safety, in which individuals feel at ease drawing attention to
potential hazards or actual failures without fear of censure from management.
In risk management, we discuss "active" and "latent" as applied to errors. Active
errors occur at the point of contact between a human and some aspect of a larger system
(for example, a human-machine interface). The results are usually felt immediately. Latent
errors can be made by any part of the team, and are often removed from the operators
control. Transcriptionists can contribute to latent errors by the healthcare team. We also
discuss adverse drug events (ADE); transcriptionists are part of the lineup that actively
has a part in avoiding adverse events involving medication use. We avoid latent errors as
editors by checking and double checking what is dictated, not guessing, and being a
detective on medications. A knowledgeable transcriptionist might know the top 200
medications and common dosages for each. He/she will double check that what sounds like
a teen is not a twenty. I cant tell you how many cheat sheets and word lists
Ive made for myself over the years, which I now use in my education site. I
sometimes develop systems, which I teach my students, to remind myself of a reminder!
(An example of this would be an autocorrect or autotext in Word that says, whether I type
dysphagia or dysphasia, check this is it speech or swallowing? I had one student who
always had the following drop onto a page affect is the verb usually and effect is the noun
usually. By seeing the printed rule drop over and over on the page, it provides a double
check, as well as a way to memorize the rule.)

We also discuss the authority gradient which refers to the balance of decision-making
power or the steepness of command hierarchy in a given healthcare situation. If there is a
dictatorial team leader, we experience a steep authority gradient. Expressing concerns,
questioning, or even simply clarifying instructions requires considerable determination on
the part of team members who might perceive their input as devalued or frankly
unwelcome. As a transcriptionist, be cognizant of the authority gradient! We must
persevere to be the best medical transcriptionists we can be, speaking out and drawing
attention where it needs to be drawn. Suggest changes which cause confusion in reading of
the patient record, and document it from three sources! Be discreet (thats not discrete!)
and be professional. If you are a team leader, effective team leaders consciously establish
a command hierarchy appropriate to the training and experience of team members, and
have an open, non-condemning ear. A person who needs to vent is a person who will
contribute.


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MTs are part of the safety culture, also called culture of safety, referring to a
commitment to safety that permeates all levels of an organization, from frontline personnel,
technologists, medical records personnel, and even to executive management. More
specifically, "safety culture" calls up a number of features identified in studies of high
reliability organizations, organizations outside of health care with exemplary performance
with respect to safety. These features include: acknowledgment of the high-risk, error-
prone nature of our work, a blame-free environment where individuals are able to report
errors without fear of reprimand or punishment; an expectation of collaboration across
ranks to seek solutions to vulnerabilities; a willingness on the part of the organization to
direct resources for addressing safety concerns. You are part of that team.
Decision Support Refers to any system for advising or providing guidance about a
particular clinical decision at the point of care. Transcriptionists are deeply imbedded in the
point of care. Accurate transcription is a big part of the equation in reliable patient
encounters by healthcare professionals. As MTs or medical language specialists, what we do
directly impacts the point of care and the moment of decision making for that possibly
fatigued physician who may or may not double check the transcription across other records
in the chart. Alternatively, perhaps not check what we may have coded into a template or
an EMR. We possibly can become part of an error chain a series of events that may
lead to a disastrous outcome. For instance, ordering an aminoglycoside for a patient with
creatinine above a certain value might trigger a message suggesting a dose adjustment
based on the patient's decreased renal function. Did the transcriptionist transcribe that
creatinine value correctly?
We speak of errors and omissions - An act of commission (doing something wrong) or
omission (failing to do the right thing) that leads to an undesirable outcome or significant
potential for such an outcome. This idea was impressed upon me in my electronic medical
record work. Sometimes the chain metaphor carries the added sense of inexorability, as
many of the causes are tightly coupled, such that one problem begets the next.
And then, there is the Health Insurance Portability and Accountability Act (HIPAA)
new federal regulations intended to increase privacy and security of patient information
during electronic transmission or communication of "protected health information"
(PHI) among providers or between providers and payors or other entities. HIPAA also
requires providers to offer patients certain rights with respect to their information, including
the right to access and copy their records and the right to request amendments to the
information contained in their records. The modern-day transcriptionist needs to have
continuing education on PHI and be part of the team and staff training regarding that
protection of patient information.
The acquisition of any new skill is associated with a lower initial success rate the learning
curve. Learning curves are inevitable; my best advice is dont be afraid of the culture.
MTs should constantly seek to improve their skills and be on the learning curve not
above being taught new ideas and admitting there is a better way to transcribe that. This
is not unique to our field, the less-then-humble persons (Ok, lets call them know-it-alls and
be done with it!) Yes, they exist in all professions. Let the MTs never be counted among the
persons who feel they cannot learn something new and already know the best way.



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Let us always be humble, open, receptive to metacognition (thinking about thinking) and
education. Let us understand whether our transcription biases or cognitive short cuts may
have a detrimental effect on the patient note! Let the medical language specialist
employ the same care and metacognition, safety culture, and sensemaking that is
applied by the rest of the patient healthcare team. Sensemaking is a term from
organizational theory that refers to the processes by which an organization takes in
information to make sense of its environment, to generate knowledge, and to make
decisions. It is the organizational equivalent of what individuals do when they process
information, interpret events in their environments, and make decisions based on these
activities.
Structure-Process-Outcome Triad Quality has been defined as the degree to which
health services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge. This definition, like most
others, emphasizes favorable patient outcomes as the gold standard for assessing quality.
In transcription, of course, one would like to detect quality problems without waiting for
poor outcomes or a misread note to cause a deviation from the best patient care. Thus is
born quality assurance (QA).
The summary isthe lingo we hear on the Army commercial (drum roll!): Be the best you
can be! (OK a little canned, but its true) Get the best education; dont be afraid of
technology and change; dont be overly sensitive to errors, but exploit sensemaking and
learning skills; and be a part of your professional organization (AAMT). Be a technologist
(root word being knowledge) in your chosen field. Moreover, dont be afraid to choose a
position outside of straight transcription; your skills are needed many places in todays
world. If you want to supplement your education, feel free to look us up at
www.profitmt.com. Ask us questions, well help you.

I leave you with my 15 rules for the medical transcriptionist. They are based on
being persnickety, persistent, professional, and taking pride in your work on the
team.
RULE #1 (my favorite)
NEVER GUESS
Look it upknow what it means.look it up..
know what it meanslook it up.

RULE #2
BE PERSNICKETY
Particular and precisefastidious..fussy..
Showing or requiring extremely careful treatment

RULE #3
BE PERSISTENT
Refuse to give up, especially when faced with opposition or difficultytenacitystubborn and
persevering for better knowledge.

Rule #4
BE PROFESSIONAL
Engaged in or worthy of the high standards of your profession.


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Rule #5
PRIDE YOURSELF IN YOUR WORK
Dont be proud but take pride in being a medical transcriptionist or medical word
specialist.

RULE #6
WHEN GETTING FEEDBACK, WRITE IT DOWN.
Dont get caught in the trap of taking corrections personally.

RULE #7
BE A DETECTIVE!
Be a word person; care about words. NEVER take a whatever attitude. Try to be the
best! It DOES matter.

RULE #8
BE FLEXIBLE AND INSTRUCTABLE
Be honest about what you do and dont know. Flag what you dont know or cant hear.
Learn, and learn some more; rules change. Listen to your authors and your clinics, be in
their court.

RULE #9
SAVE EARLY AND SAVE OFTEN
Use reliable backups

RULE #10
BE HIPAA-COMPLIANT
Care about the safety of protected patient information. Always be confidential; never
discuss or reveal patient information.

Rule #11
TAKE A BREAK
Be aware of the role of "human factors"-the effects of fatigue in perceptual and omissions
errors. Plan with care your time, breaks, and rest.

Rule #12
GET CONTINUING EDUCATION -GROW AS A LANGUAGE SPECIALIST
Take classes; make your goal that of being a Certified Medical Transcriptionist after training
and 2 years of acute care. Find excellent education.

Rule #13
CONTRIBUTE TO OTHERS AND BE CONTRIBUTED TO.
Try a new method; do some new research; share your learning with others.

Rule #14
KEEP YOUR PERSPECTIVE
Have a sense of humor; go easy. Remember what is important, the whole team providing
healthcare.

Rule #15
BE A PART OF THE CULTURE OF SAFETY AND RISK MANAGEMENT
Participate in metacognition and sensemaking in dictation given to your care.