A Unique Scribing Model: The COMET Fellowship for College Graduates

Like many of her recent college graduate peers, Cat Carragee was unsure how to get from here to there. There was likely a job in the health professions, perhaps as a doctor, but here wasn’t where she needed to be.

Here was working as a scribe in the emergency department at O’Connor Hospital, where the pay was minimum wage and she needed odd jobs to make ends meet. While she was getting some exposure to clinical medicine (“as a scribe you’re there to help the doctors, and any clinical learning is just a sideline,” she says), she also wanted research experience to strengthen an application to medical school. But jobs as a clinical research assistant require years of experience plus work done in the field.

Then COMET fell into her lap, and her life took a turn for the better.

COMET (Clinical Observation and Medical Transcription Fellowship) is the brainchild of Steven Lin, MD (clinical assistant professor, primary care and population health who, seeing his colleagues burning out from what he describes as “an explosion of administrative or desk work that is being put on the shoulders of primary care physicians plus the frustrations with the inefficiencies of electronic health record (EHR) systems like EPIC,” proposed a scribe service model with a twist. He learned that many scribes are pre-health students interested in a health career, perhaps going on to physician assistant or medical or nurse practitioner school. He thought that having a longitudinal relationship with one or more providers would be valuable in the eyes of admissions committees for these students-to-be, as would “opportunities to stand out and get experience.”

Scribing, he thought, “was an obvious place to go to, but I wanted to do it in a way that was a win-win-win scenario. Could we provide a different experience than the traditional pay-for-service scribe model, one that would benefit the scribes so that they could go on to achieve their dreams of working in the health profession?” At the same time, could this model “be of tangible help to our primary care physicians, be meaningful, decrease their work responsibilities in terms of charting and the EHR so they could spend more time with their families?”

Lin further describes COMET: “So that’s how the idea of a post-baccalaureate scribe fellowship came about. We are the first in the nation to come up with this model where a mentoring relationship is central. We are committed to the scribes and their education. They are paired with one to three physicians that they work with an entire year. These are faculty members who mentor them, teach them at the bedside, do scholarly research projects with them that scribes then go on to present at national conferences. We write letters of recommendation for them and mentor them on their applications and their career development. So far, since we started the program in 2015, it’s been really a good experience for both our scribes and our providers.”

Cat Carragee could not agree more. After being one of the two pilot COMET fellows in 2015, she spent one additional year as chief scribe, helping to orient and support the incoming class of six fellows and looking into ways to expand COMET to more clinics. She’s done with that now, though; in September she starts medical school at The University College Dublin. She has reached her there.

Two of the six fellows from the 2016-17 second year of COMET provide somewhat different perspectives from Carragee’s.

Tuan Nguyen describes his post-baccalaureate plans as “just a mess. I had recently finished my bachelor’s degree in physiology at San Francisco State University, and I had the idea of going to medical school. I knew that my application right out of college was not strong enough. I learned about COMET from Marcella Anthony, one of my mentors who had been program coordinator of the Health Career Opportunity Program, which I was in during 2013. I thought ‘oh my gosh, this is just what I need!’ This was the all-in-one CARE package that I needed so desperately.”

Scribing was a challenge for Nguyen. “I was terrified my first few days. I had a lot of doubt and anxiety. But in Stanford family medicine they understand that. The culture is welcoming and open and nurturing. So when I walked in there, right away people came up and asked how my morning was going and acknowledged me. It reminded me of the very supportive environment I was in. I wasn’t completely on my own.”

Nearing the end of his fellowship, Nguyen was scribing with a new provider, Valerie Teng, MD, and had a moment when he felt “so proud about my scribe performance. I had finished the note on time and Dr. Teng went through the entire thing and said she wouldn’t have changed more than a word or two. Oh my gosh, fist pumping! It was a moment of celebration.”

Nguyen had four official mentors during his fellowship: Megan Mahoney, MD; Amelia Sattler, MD; Kendra Patton, PA; and Steven Lin, MD. But, he says, “I feel like every provider in family medicine was more or less a mentor to me.”

We are committed to the scribes and their education.

For 2017-18, Nguyen will be co-chief scribe in the COMET fellowship program; the other co-chief will be Eugenia Jernick who learned about COMET from her father, a family physician at Stanford. “He knew I was looking for clinical and research experience, so he forwarded me the application,” she says.

Jernick had one mentor during her fellowship, Nancy Morioka-Douglas, MD, MPH, and she describes their working together as “pretty great. She was very open to answering questions, even answering my questions before I could even ask them. I really got to know her and her patients throughout the year. We developed a very special connection.”  

Jernick’s research project got her invited to a national conference for family medicine where “I presented a roundtable discussion with Dr. Lin. My research was about bringing to light the decline in maternity care in family medicine and how that may affect medical students’ views on going into ob-gyn. The roundtable discussion lasted about an hour and I received some interesting insight into the solution that I proposed.”

Summarizing her fellowship year, Jernick says, “I got so much out of it, not only learning clinical skills but about family medicine and medicine in general. I gained a lot of confidence and I learned about my leadership skills. COMET has definitely brought me a long way from where I started. I was a little unsure about whether I wanted to go into medicine in the beginning, but now I’m 100% positive that that’s what I want to do.”

And how did helping fellows get from here to there help their mentors? Is COMET the win-win-win program Lin envisioned? In a manuscript soon to be published in the Annals of Family Medicine, Lin and colleagues present the results of looking at physician and patient satisfaction and charting efficiency. Lin summarizes his thoughts about COMET: “What the scribes provide the physicians is relief from the documentation burden. We’ve seen that they are increasing our physicians’ ability to close their charts on time. Our providers say that they go home on time, have weekends free to spend time with family, get to work on teaching and research. They don’t have to worry any more about the piles of charts they have to complete every week. It’s really been a great benefit to our physicians.”

As for the scribes’ overall response to a question about whether they were glad they were COMET fellows, Carragee said it well: “Oh my gosh, yes!”