ESL dictation? Bring It.

When medical transcriptionists –whether seasoned, or newly graduated – get together and “talk shop”, it's almost a given that someone will bring up ESL dictation… and everyone else will nod, groan, and roll their eyes.

ESL: English as a second language. In medical transcription it's defined as dictation by individuals who speak other languages in addition to English, and whose accents (and often syntax) are colored by their native tongues.

Here's a thought to consider: There's almost no such thing as UN-accented English, even from native speakers. It's largely a subjective call. One's perception of whether or not a speaker has an "accent” has less to do with the speaker's region of origin than one's own. In any case, it can't be assumed that dictation from a physician born and raised in the USA is going to be any easier to decipher than that of his colleague who immigrated from Kenya or Pakistan or Brazil. 

Case in point: My introduction to medical transcription. Here's the story.

Newly graduated from a medical assistant course in the early 1970s, I took an entry-level position in a hospital laboratory. My duties involved accepting specimens, time-stamping the requisitions and verifying that patient names matched the container labels, and then taking them to the appropriate areas of the lab for analysis. This was in the days before everyone who came into contact with bodily fluids wore gloves. Let's just say it was sometimes a messy job.

My desk – a table, really – was positioned in a busy hallway, and in the steady stream of employees passing by was a gracious and regal lady, about my mother's age and nearly six feet tall, who always had something nice to say to the lowly specimen clerk. She was the supervisor of a small team of pathology secretaries. I had no idea what they did, but I figured it had to be better than gingerly unwrapping damp requisitions from slightly leaky pee jars all day.

She thought so, too. One morning, she stopped by my table to ask whether I ever had done transcription. I hadn't, but I could type pretty fast and knew medical terminology(with my brand-new medical assistant certificate to prove it). In her customary cheerily brisk manner, she said “well, come with me and let's try something”. And with that, off we went down the hallway.

In one of the pathology offices, she directed me to sit at a desk. An IBM Selectric was in front of me, a foot pedal was on the floor, and a microcassette player/transcriber on my left. She put a tape in the latter, handed me a headset,explained the foot pedal, and then cranked a sheet of paper into the Selectric and told me to just type what I heard.

I touched the foot pedal, and listened.And listened. I backed up and listened again. And again. My fingers,poised over the keyboard, hadn't moved. She asked whether I could hear it okay, if we needed to adjust the volume.

“Is this Dr. ____?”, I asked,because it certainly sounded like one of the pathologist's voices.Yes, she replied. I listened once more, then asked “Is he speaking English?”

I had no idea at the time why she found that so funny. Once she recovered her composure from laughing, she explained that the doctor we both knew – who had been born and raised locally – was, in fact, speaking English. It may have sounded like he was at the bottom of a well, but that was because he had dictated in a small room with background noises including occasional running water. It was gross pathology dictation. What he had said at the beginning was “Thespecimen consists of ...”. On that day, though, I heard something very much like “tepezcah sisah”. Definitely, to my untrained ears, not English.

I had not yet developed my auditory discernment, the essential attribute that defines the difference between a typist and a transcriptionist in terms of skill. Nor did I realize, yet, that my “transcriptionist ears” would have to be re-trained with every voice I heard for the first time.

I learned quickly, though, thanks to that supervisor's mentoring. After happily transferring out of specimen purgatory with a promotion to pathology secretary, several months later I was flying through gross and micro dictation with ease and knocking out my fair share of postmortem reports too.

I earned a reputation for speed,accuracy, and a can-do attitude, or so I was told one day by a new resident as she was introducing herself to the clerical staff. The first female resident we'd seen (in the 1970s, women were only just beginning to be visible in that specialty), she stood out for another reason, too: She was from South Africa, and spoke with an accent we found charming and fascinating until we heard it through our headsets. Just like that, I was back at square one: “Is she speaking English?” She was, indeed. Her native English. Might as well have been Martian. My ears were – again! – clueless.

I approached it as I had when I first put on a headset and listened to my hometown doctor: Just keep listening, pick out the words you can hear, go back and see if you can fill in some more, take note of unfamiliar syntax, repeat as necessary. Repetition eventually results in recognition. The "aha" moments.

Granted, we were not under the pressure of a production pay system where minutes lost are dollars lost. We also had access to the dictating pathologists and residents, and freedom to ask “what in the world did you say here?”, or even to ask them to listen through our headsets. And of course we could call on each other for a second opinion, which is an advantage to in-house transcription that I truly miss.

This was before medical transcription was even a recognized career field, though – with AAMT itself still a few years away from formation – and we either figured out how to “train” our ears to each new voice we heard and embraced the challenge, or we gave up and did something else for a living.

I'm still here. And so is ESL dictation. 

By my own informal estimate, the acute care transcription I'm doing today is 75-80% ESL (as defined above) whereas 10 years ago it was about half that. A transcriptionist's competence and level of comfort with ESL has become a critical factor in hiring, and indeed many MTSOs now ask about it directly on their employment applications. However that inquiry is phrased, what they really want to know is “does ESL dictation throw you? Areyou apt to cherry-pick around the tough ones, or will you take whatever comes up next in your queue?” Our facility, or lack of it, with ESL dictation directly impacts TAT. And failure to meet contracted TAT means loss of accounts.

Fearless transcription (or SR editing)of ESL dictation gives us an edge, no question. So how do we become fearless? How do we get past that sinking feeling when we see a 10-minute dictation from Dr. So-and-so in our queue, knowing it's going to take most of the next hour to complete? How do we get from “there goes my line count” and fleeting desperate thoughts of how to justify throwing it back into the pool (“hmm, I could take my break now … oh, wait, if there's a power outage it'll go back! Where's the off button on that power strip?”) to just shrugging and getting on with it?

My approach – which I still employ when a especially challenging new voice comes up – goes all the way back to my pathology days: If you can't avoid 'em (and we can't),embrace 'em.

1. Immersion. I've been known to actually ask for the tough ones, and not only particularly difficult ESL. When I first began doing acute care, for some reason orthopedic op notes threw me for a loop regardless of who dictated them. I knew the anatomy backward and forward (my initial training had been augmented a few years later by a rigorous EMT course, plus I'd briefly done office transcription for an orthopedic group) but I got completely lost in total hips and total knees, and all the components and screws and cuts and templates.
   
   
   So (it's okay, I'm accustomed to my sanity being questioned about this) I asked for as many as possible to be routed to me. Same with occasional ESL speakers whose syntax and pronunciation combined with  the speed and volume of their speech made them exceedingly difficult to transcribe. It was not an enjoyable process, and my line counts took a beating temporarily. But it paid off in the long run. Rare is the day, now, when I don't meet (or even exceed) my line count and QA requirements, regardless of who's dictating that day's reports.

2. Collaboration. It's not as easy in these days of home-based isolation, since we certainly can't ask the transcriptionist in the next cubicle to “give a listen”. But if we're connected via IM to co-workers, a quick message (“Help – Dr. X is dictating, s/l this”) effectively puts two (or more) heads together on the problem. Likewise, a transcriptionist message board on the Internet will usually have a “word help” section to post something similar, and I've found that some highly skilled and knowledgable MTs make a point to check those often. (I think these gems of our MT world are paying forward for help they've received along the way.)

3. Research – or as I like to call it, detective work. If the transcription platform we're using allows a “report search” function to look at previously transcribed reports, and (better yet) keyed to search on a particular physician name, we may find that someone else has figured out a few pieces we're still struggling with. In the absence of this, there's the magic of Google. Often, if I type in what I think I hear, among the possibilities that come back is the one that says, bingo!

4. Feedback. If all else fails and a report with so many blanks it looks like Swiss cheese must be sent to QA, I make a point of asking to see the corrected copy. Sometimes this requires persistence and repeated requests if QA feedback isn't routinely done. There's constructive QA, and then there's punitive QA. But it doesn't hurt to ask.

Fearlessness and confidence in transcribing or editing ESL dictation is possible, andit's an advantage when MTs need all the advantages they can get. ESL is one of the realities in our profession that isn't going away, but most of us are better equipped to deal with it than we think.

We've been listening to “accents”and filtering out extraneous noise all along. Much as our eyes are constantly adjusting focus and our brains interpreting the images transmitted along our optic nerves, our auditory discernment is also constantly assembling sound waves into coherence. 

We have the ability. All we need, then, to be fearless about ESL dictation is determination. If we didn't already have that, we wouldn't still be in transcription.