a b s t r a c t

Background: Due to the unique nature of working in the field of emergency medicine (EM), physicians often find it difficult to engage in research and scholarly activity while also working clinical shifts. Barriers to engaging in both academic and clinical work include lack of time, resources, and incentives. EM physicians are familiar with the concept of scribes working alongside them in the emergency department, and there are multiple papers published that examine and advocate for their benefits.

Objectives: This paper aims to introduce the concept of virtual research scribes in clinical research in EM to offer physicians an opportunity to alleviate the burdens of balancing clinical work and academia simultaneously.

Methods: A research scribe is a student who is interested in healthcare and research and aids the PI in literature reviews and manuscript writing and editing, completely remotely. Six research scribes were hired in a pilot pro- gram to test their efficacy in a clinical research setting. The scribes were assigned tasks including manuscript writing and editing, performing literature reviews, and writing newsletters.

Results: The six research scribes in the pilot program proved to be beneficial for time management, collaboration, and editing in the research and scholarly process. The remote nature of the program allowed for flexibility in scheduling on both the PI and scribe’s behalf.

Conclusion: By utilizing a research scribe in their academic career, EM physicians can increase efficiency and pro- ductivity in scholarly work.

(C) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Emergency medicine (EM) is a unique specialty given the spread of work hours, intensity of work during shifts, and variations in scheduling weekly [1]. Emergency physicians who work frequent clinical shifts find it challenging to engage in the research and scholarly activity process. This leads to a loss of activity or work that could potentially contribute to the science of emergency medicine. Historically, it has been difficult for departments to find research-focused faculty, and the core faculty also frequently struggle with meeting the residency review committee (RRC) requirements for scholarly activity [2-4].

However, research and scholarly activity is a slow and iterative pro- cess, which builds over time and needs continuity, dedicated focus, and commitment of time. Also, the research writing skills that are used in re- search are often very different than the writing skills physicians are used to in their professional lives. Often physicians have great ideas, but there are many barriers in penning them down during multiple

* Corresponding author at: Emergency Department, Southside Hospital, 301 E Main Street, Bayshore, NY 11706, United States of America.

E-mail addresses: [email protected] (N. Garg), [email protected] (P. Kumar), [email protected] (S. Gupta).

stages of the research process [5]. For example, writing an IRB proposal would include background research and a literature review, and inte- grating ideas from different papers into a 2- to 3-page format. Once the study is approved, besides the Research staff aiding in the analysis of the results, publication of the study also requires intense writing in terms of abstract writing and manuscript preparation, followed by man- uscript revision. Other factors that can potentially limit a physician from participating in clinical research and trials include a lack of time and re- sources to pursue a project, insufficient training or experience to carry out a study, or the absence of an incentive [5].

Research also needs a lot of collaboration. This collaboration and col- laborative correspondences are very detailed and time consuming [6]. All these factors can potentially turn away a physician due to mental fa- tigue, computer fatigue, and lack of leisure time [7]. Physicians often feel that in the beginning stages of their career they are not productive enough with these topics and are not efficient with their time. Mid-career physicians who wish to advance their career face similar dif- ficulties as well. This leads to a lot of fallout among academicians and scholarly activity gets pushed back to the least of their priorities.

Currently, in the United States there are 102 academic EM training programs, including university affiliated and university hospital pro- grams, and 83 community-based EM training programs, including

https://doi.org/10.1016/j.ajem.2021.03.034

0735-6757/(C) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

urban, suburban, private urban, and county hospital programs [19]. The common program requirements for scholarly activity fulfillment are uniform across the nation. The program is supposed to provide facilities to the faculty and residents in order to promote scholarly activity. How- ever, without substantial investment from the program in terms of obtaining a team of supporting staff academic associates and research coordinator(s) along with the research director, the cost accounts for at least $750,000 over the year including benefits. Lack of such resources can stall progress.

The utilization of research scribes can potentially solve many of these issues. Emergency physicians are quite familiar with the concept of scribes during clinical shifts [8-10]. Although there is variable re- sponse to the credibility, utility, and medicolegal issues surrounding scribes, EM groups have often found that scribes do in fact increase the productivity of EM physicians [11]. Studies reveal that the utilization of scribes in the emergency department has resulted in an increase in physician productivity during primary consultations and a decreased length of stay for patients in five different emergency department set- tings [12]. Scribes also allow for the increase in face-to-face time with the patient and their families, which can help increase patient satisfac- tion with quality of care received [13].

1. Methods
   1. Research scribe versus traditional research associate program

Research scribe is a completely remote and virtual position, which may or may not be employed directly by the employer. Research scribes can be hired by the investigator individually on an as-needed basis without an investment of a lot of money upfront and commitment. This is also especially true during the COVID-19 pandemic, as most re- search associate programs were halted and later were required to work remotely. As opposed to research scribes, research associates typ- ically are not involved a lot in the writing aspect of research and schol- arly activity process, and a majority of their role is focused on the regulatory and data collection aspects of research.

• 1. Who can be a research scribe?

I have utilized research scribes over the span of 2 years as a pilot pro- gram and have enrolled 6 research scribes to date. Being a research scribe is a good experience for students looking to pursue a career in healthcare. This is not limited to attending medical school, physician- assistant (PA) school, nursing school, a post baccalaureate program, any pre-health program, or someone who is taking gap years from school. Hence, the research scribe can be a high school student entering their junior or senior year, an undergraduate student of any year, or stu- dents enrolled in a post-baccalaureate program who are looking to be involved in research. However, the research scribe position is not lim- ited to someone who is a student. It can be anyone who is looking to pursue a career in healthcare and/or clinical research. As aforemen- tioned, this individual can be at any stage of their career path.

It is worth noting that the research scribe absolutely does not have to be a student - this position can be given to an individual who is willing to do this work for life. However, there are more ways of compensating students (i.e. with a stipend and/or publications), so this would act as a source of motivation and career advancement. This motivation is a big factor for somebody to be flexible, and that is where having a scribe who is a student is more effective than regularly hiring an employee to assist in the production of research. Table 1 summarizes basic data pertaining to the 6 research scribes in the pilot program.

The skills required for a research scribe include efficient typing; fa- miliarity with programs such as Microsoft Word, Adobe, and PowerPoint; citation management in AMA, APA, and MLA formats; liter- ature reviews; and the ability to perform meticulous editing. Students in the US are often familiar with these skills to some extent prior to being hired due to their exposure in an academic setting, such as conducting literature reviews for research reports or scientific writing for premed- ical courses. Research scribes usually work remotely over the phone at variable schedules predefined by the principal investigator (PI). These are seasonal jobs in the sense that when the scribe moves on to their next endeavor, hopefully they can refer other students who are in the same boat open to word of mouth suggestions.

The versatile nature of the work call provides flexibility to both the PI and research scribes themselves, who are usually in school, to work at different hours. The “scribe calls,” as I refer to them, are typically 45 min long, and further extension of work can be delegated to the scribe in terms of editing and formatting.

• 1. Research scribe training

Research scribes are trained by the PI at multiple levels. This training is usually project specific and is done as the time goes by in small pieces. For example, during the pilot program, the PI was working on a project and had collected a large amount of data from a quantitative survey from various institutions, so a scribe call was set up to teach the scribe how to conduct an analysis of the data using Excel. The scribe was en- couraged to ask clarifying questions and seek help and practice from outside sources as necessary. The analysis was spot checked by the PI to ensure it was being done correctly. This is just one example of many that exemplifies how the research scribe position is a “train as you go” job. Since the scribes are motivated and are familiar with these programs from their academic lives, it does not take a significant amount of time on behalf of the PI to train the scribes.

An iteration of this program is the PI is a research director and trains multiple research scribes at once. The already trained scribes are then referred to young or mid-career physicians in an attempt to aid them with their research and scholarly activity. This way, physicians do not have to be concerned with minor setbacks due to lack of training and can efficiently kickstart their projects with the aid of a scribe.

The scribe starts out with busy work during the beginning stages of

their appointment- writing emails, transcribing interviews, performing literature reviews, etc. They then gain insight onto manuscript writing by helping the PI edit manuscripts already in progress. After some

Table 1

Summary of research scribes in pilot program.

Scribe?	Status at time of employment	Hours Worked	Duration of Employment	Co-author of manuscript	Status after term of employment
A	Pre-med undergraduate student	30	6 months	No	Attending medical school
B	Pre-med undergraduate student	50	19 months	Yes	Attending medical school
C	Pre-med undergraduate student	23	6 months#	No	Pre-med undergraduate$
D	Pre-med undergraduate student	20	5 months	No	Full time position (goal is medical school)
E	Pre-med undergraduate student	220	19 months#	Yes	Pre-med undergraduate$
F	Pre-med undergraduate student	10	1 week#	No	Pre-med undergraduate$

* names redacted.

^# continuing position currently.

^$ Currently studying for the Medical College Admission Test (MCAT) to apply to medical school.

exposure to scientific writing and editing, the scribe is given the opportu- nity to contribute significantly to a manuscript and earn co-authorship.

A large orientation, training manual, or orientation program is not needed for the research scribe position because the scribe can be acquainted to a specific task as it arises and then complete the task. This research scribe program structure does not include an extensive hiring process and works exceptionally well to fulfill small gaps where one stumbles in the research and scholarly activity process. The beauty of this program is that it is flexible and anyone can set it up relatively quickly.

1. Advantages of research scribes

There have been multifold advantages to utilizing a research scribe [14]:

1. Time Management: One can accomplish more productive work within the same amount of time when working with a research scribe as opposed to working alone.
2. Personal Study Group: You always have a person to discuss your ideas with, and research scribes often reflect on your thoughts and provide constant feedback.
3. Editing: Research scribes act as the second pair of eyes for your draft at all times and can be great editors.

This position also benefits the scribes in terms of understanding the reasoning and thought process of the investigator, while also learning how to write a manuscript, correspond with collaborators, and write a proposal. This is an immersive research experience because the research scribe has been involved in every step of the research process and learn in vivo the understanding, assertion, and thought processes of the in- vestigator at all times. They also go through the process of communicat- ing with other collaborators and learn how to write, re-write, and edit manuscripts based on feedback from other collaborators. Research scribes are trained at multiple levels, including performing literature re- views, writing a research paper, abstract preparation, writing a manu- script, and writing newsletters. The overall performance and academic output generated with the research scribe pilot program is summarized in Appendix B. All interviews listed in this table have been transcribed by a research scribe for publication online, and all newsletter have been transcribed and edited by a research scribe. Research scribes were also involved in assisting with the production of manuscripts pub- lished in peer-reviewed journals and publications in pipeline.

1. Key issues

The key issues that arise with the bottom of the concept include the following:

1. Protection of intellectual property. Investigators are at risk of compromising their intellectual property because they are discussing unrefined ideas with another person, who is essentially documenting everything and keeping it on file. This can potentially make their work vulnerable, and risk losing rights on their intellectual property if handled improperly.
2. Trust and confidentiality agreement to not forward or share infor- mation with anyone under any circumstances.

Nondisclosure agreement (NDA), commonly referred to as a confi- dentiality agreement, is a contract between the employer and the em- ployee (the PI and the research scribe in this case) that is established at the beginning of a term to protect intellectual property and ensure unrefined and novel ideas are not discussed with others [15]. Not only is it important to establish an agreement as such prior to hiring and working with research scribes, it is also essential to pick a research scribe you can trust by having a screening process for employment which can involve, but is not limited to, submitting an application for the position, submitting a resume/CV of relevant past experiences, a re- ferral by a current or previous supervisor, and an interview.

These issues can easily be solved by having a legal document created by your lawyer, which is mutually agreeable, and binds the scribe not to share the ideas discussed with anyone [16]. An agreement would be created that indicates that the research and work discussed is the intel- lectual property of the PI before progressing with work.

1. Compensation for research scribes

Scribes can be compensated in multiple forms.

1. Monetary compensation. When I piloted the program, the position was purely based on mon- etary compensation at the comparable minimum wage rate of $15.00 per hour, as the scribe is not travelling, and the work conditions are also very flexible [17]. This position can be self-funded, department funded, or funded by Research Grants. If the research scribes are di- rectly hired by the PI there is less complexity, but more complexity if hired by the institution in terms of hiring and in terms of employ- ment. Alternatively, the department can provide no-budget funds to compensate for such facilities in the long run. Investigators monetar- ily reimburse approximately 80% of the total hours a research scribe works. During the pilot program, $2300 was allocated across the 6 re- search scribes in exchange for their numerated work hours.
2. Intellectual compensation.

Holding the position as a research scribe can also count as research experience for their pursuits, and the investigator can attest to the scope and hours worked. According to the American Medical College Application Service (AMCAS), the average medical school matricu- lant reports approximately 1200 research laboratory hours on their medical school application, which can be accumulated by working in a laboratory during the school year or during summer months, tak- ing a laboratory-based class for credit during the semester, working with a professor or organization conducting research, or by working as a research scribe as well [18]. If the scribe has enough contribution and editing, they can also be listed as a co-author and gain intellectual compensation which will help them with career advancement. Being involved in a publication to report on one’s academic record can help enhance the applicant’s application for further education or careers, highlight the applicant’s intellectual achievement, and act as a contri- bution to the collective scientific community.

1. Numerated and Non-numerated hours.

Research scribes can be compensated for both numerated and non- numerated hours. Work such as writing emails for correspondence, transcribing interviews, performing literature reviews, and editing letters can account for the scribe’s numerated hours in which they are monetarily compensated for their time accordingly. Scribes will be responsible for tracking their own hours and updating their PI regularly for payments. For work that is done on a manuscript, newsletter, or any form of publication in which the research scribe has gained co-authorship, the hours put in will count towards non- numerated work and the scribes will receive intellectual compensa- tion instead. This gives the research scribe the ability to report this work on academic and professional applications, and the guarantee that the PI will attest to his/her contributions to the publication. Scribes should log their own hours on a spreadsheet that is shared with their PI so both numerated and non-numerated hours can be accredited accordingly (see Appendix A for a sample log sheet).

1. Conclusion

Research scribes are a highly effective tool and technique for young investigators, especially for those working in community-based EM set- tings and have limited access to resources. Research scribes are another tool that one can add to their research toolbox and utilize effectively. EM physicians involved in clinical research or looking to be involved in

research and scholarly activity are encouraged to hire research scribes to help alleviate the burden that both clinical and academic work can impose. The research scribe program is novel and flexible, and EM phy- sicians can manipulate the program according to their requirements and needs.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Author contribution statement

The idea for this concept paper conceived by NG. SG and PK were in- volved with elaborating on the idea. NG, SG, and PK were involved with editing and writing the manuscript. PK is currently one of the research scribes in the pilot program.

Declaration of Competing Interest

None.

Appendix A. Sample of Scribe Hour Log Sheet

Date	Work Performed	Numerated vs Non-numerated	Time	Minutes	Payment Due
6/25/20	Phone call for newsletter	Numerated	2:00-2:45	45	$11.25
	Newsletter Editing	Numerated	2:45-3:00	15	$3.75
6/29/20	Manuscript Editing	Non-numerated	12:00-1:00	60	$0
Total				120	$15.00

Appendix B. Overall Performance and Productivity of Research Scribes

Category Works Generated with Scribes Total

Peer Reviewed Journals

Current Unfunded Projects

Publications in Pipeline

Garg N, Yang J, Pekmezaris R, Stevens G, Becerra A, Levy P, Kumar P, Sayeen Nagarajan M, Becker L. acuity patterns of Heart Failure in a Large 2

Health System’s Emergency Departments. American Journal of Emergency Medicine (In Press) Ref. AJEM24758R1

Garg N, Stevens G, Haddad G, Kozikowski A, Pekmezaris R, Patel V, Kumar P, Becker L. Performance of Emergency Heart Failure Mortality Risk Grade in the Emergency Department. Western Journal of Emergency Medicine: Integrating Emergency Care with population health (In Press)

Diagnosis Disparity in Congestive Heart Failure (CHF) Between Emergency 4

Medicine and Hospital Medicine Study Number: 19-1106-SH

Experiences and Observations of Case Managers and social workers with Admitted CHF patients: A Qualitative Study Study Number: 19-0838-SH

Difference in the Pretest Probability of Disposition Between Emergency Medicine Physicians and Cardiologists Based on the Initial Presentation of the Patient with CHF in the ED Study Number: 19-1083-NSUH

Retrospective Analysis of Psychosocial Factors and Social Work Interventions on Readmission and Mortality among Congestive heart failure patients

Study Number: 20-0947-FIMR

Garg N, Hargous, E, Totten VY, Greenberg MR, Wilkerson G, Finell II JT, Lau WB, Brody AM, Miner JR, d’ Etienne JP,Janke AT, Camargo CA. An 2

Overview of Scholarly Activity in Emergency Medicine residency training programs.

Garg N, Kumar P, Gupta S. Concept of Virtual Research Scribes in Clinical Research in Emergency Medicine.

Newsletters Concept of Research Scribes in Clinical Research in Emergency Medicine. New York College of Emergency Physicians Empire State Epic: 7

https://www.nyacep.org/images/EPIC/37-04-20.pdf

Top Five Tips for Junior Clinical Researchers. New York College of Emergency Physicians Empire State Epic: https://www.nyacep.org/newsletter- feb-20/16-newsletter-aug-20

Research Involving Children: Ethical Considerations. New York College of Emergency Physicians Empire State Epic: https://www.nyacep.org/ newsletter-dec-2020/17-newsletter-dec20

Scholarly Activity, Research, Scholarly Activity, and Innovations Section for ACEP: https://www.acep.org/how-we-serve/sections/emergency- medicine-research/news/february-2019/scholarly-activity/

Introduction to Section Officers: https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/february-2019/2. introduction-of-section-officers/

Section Objectives, Vision, and Officers: https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/october-2019/ section-objectives-vision-and-officers/

Message from the Chair, Research, Scholarly Activity, and Innovations Section for ACEP: https://www.acep.org/how-we-serve/sections/ emergency-medicine-research/news/february-2019/message-from-the-chair/

Interviews Interview with Dr. Lance Becker (Part 1): https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/may-2017/ 5

interview-with-dr.-lance-becker-part-1-of-a-2-part-series/

Interview with Dr. Charles Cairns: https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/cairns-interview-2018/ Interview with Dr. Lance Becker (Part 2): https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/october-2017/ interview-with-dr.-lance-becker-part-2-of-a-2-part-series/

Interview with Dr. Camargo: https://www.acep.org/how-we-serve/sections/emergency-medicine-research/news/october-2017/interview- with-dr.-camargo/

An Interview with Dr. Stephen Bernard on Therapeutic Hypothermia: https://www.acep.org/how-we-serve/sections/emergency-medicine- research/news/september-2015/an-interview-with-professor-stephen-bernard-on-therapeutic-hypothermia/

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