Secrets of Handling ‘The Great Dictators’ in MT

“When people talk, listen completely. Most people never listen.” – Ernest Hemingway

“Most people do not listen with the intent to understand; they listen with the intent to reply.” – Stephen R. Covey

“We have two ears and one mouth, so we should listen more than we say.” – Zeno of Citium (Greek philosopher)

All right, that’s enough. I think you know where I’m going with this. Everyone knows that medical transcription is all about listening. But no one tells you that the hard part is learning to listen. Every time an MT gets a new doctor, he/she has to learn the dictator’s style, accent, and preferences.

Clinics and hospitals cannot do without MTSOs (medical transcription service organisations). It is their transcripts that help dictators in malpractice cases, their connection if they forget to dictate a letter needed for pre-authorisation, and their go-to person who puts their words to print. At one time or the other in their career, most MTSO employees have felt that what they do does not matter to anyone but themselves, but the truth is that it matters to the doctors, nurses, insurance companies, malpractice attorneys, and last, but certainly not least, the patients themselves (even if they don’t know it).

In spite of this, not all dictators take care while dictating. MTs do not expect dictators to speak in slow motion, spell out every word, or exaggerate enunciations. But sometimes it becomes very difficult to make out what a dictator is saying. They may eat while they’re talking and they mumble or stutter, or they’re tired and they yawn while dictating. Occasionally, they forget there is a human at the other end of the process who has to figure out exactly what is being said.

A bad dictator can spoil the whole day for an MTSO employee, since not only is the transcribing MT forced to reduce speed in order to concentrate on accuracy, but the QA who proofreads the file also has his/her other files held up due to that one poor dictator. Also affected are other MTs and/or QAs whose assistance is sought with the dictator.

Given below are some of most common problems faced by MTSOs.

• Dictating punctuations

Most dictators assume that the MT will insert the correct punctuation where required, but some dictators tend to specific them by saying “comma”, “hyphen” and “period” or “full stop.” If the MT doesn’t realise what that word is, he/she may struggle to figure it out, and thus lose precious time and effort. Solution: Practice. 

• Word endings

Sometimes, the dictator may not pronounce the final letter or syllable in a word or may add one instead. For example, fine instead of find, ih-stop instead of stop, or fever-ah instead of fever. Solution: Practice. 

• Sound substitutions

Letters and sounds that are present in one language may not be present in another. So, since not all dictators are native speakers of English, they might exchange the sound or letter with the closest one they know. The exact substitutions vary by culture, but some are listed below:

COMMON SOUND SUBSTITUTIONS

Actual Sound	Dictated Sound
sh (she, sheet)	ch (chee, cheet)
th (this, these, catheter)	D, T, or Z (dis/tis, dees/zees, cadeter)
G or J (gentleman, just)	Y (yentleman, yust)
W (wound, white)	V (vound, vite)
V (virus, Vicryl)	B or W (birus/wirus, Bicryl)
L (collect)	R (correct)

Solution: Practice. 

• Changing genders and tenses

If a dictator starts out by clearly stating that the patient is male or female and then halfway through the dictator randomly shifts between the opposite pronouns (she/her or he/his), it is okay to change it back to the correct one. The same rule applies for random change of tense – past, present, and future – in the course of the dictation. Solution: 1. Alertness. 2. Use Ctrl + F after completing transcription to search for gender or tense changes through the dictation. This is actually advisable for all dictators over all files. 

• Hesitation sounds and pauses

Some dictators tend to say hmm, ah, eh, er, etc. when thinking about what to say next. If a word is unclear try to figure out if it might be one of these words. Solution: Alertness and practice. 

• Incorrect dosages

Some dictators might dictate incorrect dosages, which could be catastrophic. Because treatment decisions are based on information in the chart, accuracy is crucial. A good transcriptionist must therefore cross-check all dosage information dictated, by either using software such as the QuickLook drug index or by looking it up on the Internet. If a doubt still exists in the MT’s mind, he/she must time-stamp or highlight the dosage so that it may be verified by the dictator or the concerned healthcare worker.

As you can see from the above, the solution to most problems with poor or difficult dictators is practice since, as they say, practice makes perfect, and doing something over and over is the best way to learn it well. Though practice takes both time and effort, it is ultimately of tremendous benefit to those wishing to pursue a career in MT.

Given below are some other suggestions to handle such dictators.

1. Reducing the bass or speed: Many physicians are so bad at dictating that you need some special techniques to understand exactly what they are saying. If you find it very difficult to understand a particular dictator, try these approaches: Try to reduce or remove the “bass” to hear the words more clearly. You can also try adjusting the audio file playback speed from very slow to fast. Sometimes varying the speed can allow one to pick up on what is being said.

2. Telling it like it is: One of the best cures for a chronically bad dictator is to return transcription with every questionable word or passage left blank. By doing this regularly, you are indicating that the dictation is constantly poor. If someone, including the bad dictator, tries to imply you just don’t have the skill to perform their work, show them successful transcriptions you have done from other physicians who know how to dictate properly. When all else fails, simply refuse to do their work, if you are in a position to do so.

3. Quiet work environment: Seasoned medical transcriptionists know how important it is to have their surroundings as quiet as possible. If you work from home, you may find that working in the evening or through the night becomes the most productive time for you, if you can fit that kind of shift into your life. If working in a pool of MTs and QAs, ensure that your work environment is peaceful as it can possibly get.

4. Taking a break: Things always seem better when the mind is not fretting or worrying about anything. So try taking a break – eat a snack, drink some fluids, talk to a relative or friend, listen to some music or just take a walk – and then come back to the dictation with a fresh mind.

5.  Asking a colleague: Medical transcription is one of those fields where egos should be left at the door along with the lunchboxes. Nobody, and I mean nobody, can give 100% accurate files at all times. Every MT and QA requires help at one point or another. So do what most MTSOs implore, request and advise their employees to do: never hesitate to ask a co-worker or a superior for help when it comes to difficult or hard to decipher words or phrases. This becomes even more important when processing files of difficult dictators.

6. No guessing: The first and foremost quality of a good transcriptionist is that he/she should avoid guessing what is unclearly dictated or heard. If the problem dictation involves drug names, drug dosages, patient-described symptoms, etc., guessing incorrectly could have dangerous, even life-threatening implications if the error goes unnoticed through the health system. The safest, most professional and ethical approach is to leave a blank in the transcription, preferably with a time-stamp.

The above suggestions are based on years of experience and research into the field. However, each MT needs to develop a system that works for them with the difficult dictators. Maybe you go through the entire report and leave blanks where you are stuck, coming back to listen at the end. Maybe you have a rule about how long you will try to get something before you send it to QA for help. There is no right or wrong answer here; everyone has their own system. What is important is finding a system that works for you and using it to make things easier.