Bob Wachter, Digital Doctor Author, Interviewed

Robert A Harrington, MD; Robert M Wachter, MD

Disclosures

July 23, 2015

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Robert A Harrington, MD: Hi. This is Bob Harrington from Stanford University here on Medscape Cardiology and theheart.org. Over the course of the past several months I have had the privilege to interview several colleagues in medicine who have written books, books not intended necessarily for the medical audience, but for a broader audience, where they have commented on some of the issues that are important not just to the practice of medicine, but in how all of us interact with healthcare across the country.

One area that has certainly got a lot of attention on Medscape is how physicians are feeling under siege from the overflow of information through electronic health records. In reading the forums and articles written online and some of the blogs, you get a sense that while electronic health records have promised efficiency in people's practices, they have frustrated clinicians to no small degree.

I had the opportunity to interview Eric Topol in a podcast that's published online on Medscape, and it's clear that the amount of information that will be available to practitioners in the coming years is going to be enormous. How we as a community deal with that information in a way that helps our patients and helps us as providers to take better care of our patients in a partnership is no small task. In fact, one might call it daunting. Today I am privileged to talk to a colleague who is nearby at the University of California, San Francisco (UCSF) about his latest book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age (McGraw-Hill Education). Dr Bob Wachter is a professor of medicine and the interim chair of the department of medicine at UCSF. Bob is also the long-standing director of the division of hospital medicine at UCSF. Most recently, and for the purposes of this discussion, he is the author of the New York Times science best seller The Digital Doctor. So, Bob, thanks for joining us here on Medscape Cardiology.

Robert M Wachter, MD: Thank you for having me, Bob. It's a great pleasure.

Medicine's Late Entry to the Digital Age

Dr Harrington: I have a series of questions that I will try to break into categories of how this relates clinically and what some of the educational opportunities are that might emerge as we think about the information age in medical practice. Let me start with the relatively straightforward question: why did you decide to write the book and what were you hoping to accomplish?

Dr Wachter: I will start with the second part first. I wanted to generate a national conversation about our computers, where we were and why we weren't quite getting it right. I have been anticipating the computerization of medicine for a decade or more. We are way behind the curve. Most other industries went digital a long time ago. I think any of us who takes out our iPhone and looks at the magic that computers have brought to us in so many walks of life can't help but say, "Well, once we get computerized, things will get better." And I think for me in particular, as a student of patient safety, I can't tell you the number of root-cause analyses I have been at in the past 15 years where we all said to ourselves, "If we just had computers, this would be great."

They finally entered our world in the past several years, and I found myself scratching my head more often than not. Why were doctors and patients not making eye contact anymore? Why were we seeing decreases in efficiency rather than increases? Why were we preventing certain kinds of errors but causing new ones? The main event that led to my decision to write the book occurred at UCSF a few years ago. We gave a kid a 39-fold overdose of a common antibiotic. The correct dose was one pill and we gave 39 pills. It was a completely digital environment, and we were dissecting how it happened. I just said, "Oh, my God, these computers are capable of causing breathtaking errors, and we haven't really thought deeply about how that could happen and what we need to do to make things better." So, that led me to come home and say "I need to write book." My wife is a journalist, and she said, "The only way you are going to get this right is to do it journalistically." We talked about that. She said, "That means going out and talking to a whole lot of people." I interviewed about a hundred different people from all walks of life to try to really understand where we are and how we get to a better place.

Dr Harrington: Kudos to your UCSF colleagues and maybe kudos most of all to the patient and his mother who allowed you to tell the story, because that anecdote captures people's attention.

Dr Wachter: I am very proud of the organization. At the end of hearing that case, I went up to the risk manager at UCSF whose job in part is to protect us, and I said, "I think we really need to talk about this case." She said, "Yeah, that's right. We should have some grand rounds." I said, "That's not exactly what I mean. I am not saying within the walls, I am talking about broadly," and I almost had to put out her hair, which was on fire. Ultimately, I got the permission not only of the CEO and chief medical officer, but of the patient and his mother and the participating doctor, nurse, and pharmacist. I think it's an act of both individual and organizational bravery, and my feeling is that if we don't talk about this stuff, we are never going to get it right.

Dr Harrington: It harks back to the original days of autopsy and then the clinical pathologic correlations (CPCs), of really trying to dissect cases to get at the underlying answer. In many ways, this was a digital postmortem. I give you guys a lot of credit for doing it because these are not easy. Certainly the self-reflection involved from all parties, the pharmacist and the nurse in particular, was quite moving. Did they experience that emotion as you spoke with them?

Dr Wachter: Oh, my goodness. First of all, I like your analogy, because I think in the old days we were very comfortable with the idea of a postmortem on a patient to find out what was wrong with them physiologically. The idea of doing a system postmortem is a relatively new concept in medicine, but I think it is extraordinarily powerful. When something goes wrong, we have to understand the system in order to fix its disease, and I think that was my feeling here, we had to do this.

For folks who don't know the case, the nurse was at the end of a fairly long train of errors that involved the technology and the interaction of the people with the technology. The nurse sees an order in her electronic queue that says, "This kid is supposed to get 39 pills." She looks at it and she says, "That seems kind of crazy." She was floating on an unfamiliar floor, she is a relatively new nurse at UCSF, and she said, "To get to me, it must have gone through a doctor, a pharmacist, and a pharmacy robot. She said, "I am going to check it against my technology." So, she barcodes it and, of course, she has great trust in the barcode, it saved her many times. The barcode says the correct dose is 39 pills because the job of the barcode at that point in the medication process is to defend the order. Once the doc and the pharmacist say this is correct, the barcode is designed to tell the nurse, "Make sure you give what the order says." Even if the order is crazy, the barcode tells you that, yes, you should do that. So, she ended up giving this kid 39 pills.

When I interviewed this nurse, a delightful young woman, who had a perfect record and was well-trained, I asked her, "What were you thinking?" Of course, in retrospect she knows it's a ludicrous order, but at the time and in the moment, with so many signs, including electronic signals, that it was correct, she did what humans do, which is to convince themselves that even if it seems weird, it's probably right. She said, "To tell you the truth, I was thinking what a trooper this 16-year-old is to take all these pills. What a good kid." And then she stopped and she broke down and started crying. She was deeply, deeply affected, and obviously feels terrible about this.

One of the benefits of reviewing errors like this is that she felt she was doing some good in talking about the case. Clearly, not only was it published in the book, but it was published on a website called Medium and went viral. I have heard from a lot of people who said, "I have done something like this and I never had an opportunity to talk about." So I think there is something cathartic about feeling like you are making the system better.

Digitization Killed Radiology Rounds

Dr Harrington: Yes, that comes across, so again kudos to the nurse and to you for drawing out that story. One of the issues throughout the book that resonated with me (and is implied in that anecdote) is how everyone is relying on digital connections and digital communication. You talk a lot about the culture of medicine and how you worry that we are losing some of that connectivity on a personal level. You reference our mutual friend, Abraham Verghese, who talks a lot about connectedness and the rituals of medicines. Well, one of the rituals that you mention is radiology rounds. Do you want to talk a little bit about how radiology rounds are almost a metaphor for the changing culture of medicine?

Dr Wachter: I enjoyed writing that chapter, and it was one of those epiphanies where I thought about the world of my training days. I went to med school in Philadelphia at Penn, and the central hub of the hospital was the chest reading room, because every day every team, medical and surgical, came through the chest reading room like cars coming through a car wash, and stopped. The radiologist who was seated in front of the alternator would put his foot on the pedal and find your films. He would ask the team "What's going on?" You would say, "This is a 42-year-old woman with lupus and shortness of breath." He'd ask the team, "What do you think this is?" As the med student, I would say, "Pneumonia." He would say, "No. You need to look at this. That's not pneumonia, that's TB. That's fungus. That's cancer." That give-and-take, that exchange, was incredibly rich, it was fun, it was stressful, it was our way of sense-making, not only for the primary team taking care of the patient, but for the radiologist; it was their connection to the world of direct patient care.

Radiology went digital about 15 years ago (well before the rest of medicine) in part because we started doing CT scans and MRIs that were generating hundreds of films and the cost of printing them became impossible and the cost of digital storage fell. Radiology went digital almost overnight around the year 2000. Nobody anticipated that that would do anything to radiology rounds. How could they? I went back and read the literature and interviewed some old-time radiologists and said, "Did you even muse about the possibility of it changing the nature of your relationship with the front-line clinicians?" They all said, "No, not at all." But the minute that radiology went digital, those rounds stopped. Nobody wanted them to stop, but we realized in retrospect that we went down for those rounds because that was the only incarnation of the film. It lived in only one place and the radiologist controlled it, and that's what created and facilitated the geography and the communication patterns. The minute it ended, radiology rounds ended, and now we are reading reports and we are looking at our films at home or looking at them on the floor, on the computer. That's all terrific. None of us want to go back to the days of only one copy of the film that can only be viewed in the radiology department. But we gave absolutely no thought to the notion that because the film is now digital, we have completely thrown a hand grenade in the middle of this vital communication for both clinical care and for mutual education.

As you say, that became a metaphor for the larger story, which is that digitization of the thing, whether it's the film in this case or the electronic medical record, changes everything. It changes everything about the geography, the communication patterns, how people think. Most industries, like medicine, don't give much thought to the implications of that. You digitize the thing and you continue to have all of your old processes and then, lo and behold, a few years later everybody wakes up and says, "That's not what I expected would happen." We are not talking to each other. It has changed the nature of education, or whatever it is, and we are not seeing the promised benefits.

There is a concept called the productivity paradox, which is that in every industry that goes digital, it takes often 10 to 15 years before you really see the massive benefits. It's partly because the technology gets better over time, but more important, it's that people begin reimagining the work, and so they begin to say, "All right. We now have this digital tool. Of course, we want digital X rays, it's better." Now, how do we think about the ways front-line clinicians and radiologists communicate? The way doctors and patients communicate in a digital era. I think that was probably the main point I wanted to get across, but we have to think about our work in a brand new way. Digitizing medicine is not just taking your analog world and making it digital, it's an entirely new business, and I don't think we have given it sufficient thought in order to get it right.

Recapturing the Lost Art of Communication

Dr Harrington: I could not agree more. For me, the joy of making rounds in the hospital is partly the physical act of walking around and meeting with colleagues, be they consultants who are seeing your patients, other services that want your input, the radiologist, the cath lab, all of the things that you go to look at. Yes, it's acquiring the information, but more important, it's bringing to bear the expertise in that social environment that is medicine. Both you and I like technology a lot, and yet somehow we have to figure out a way to take advantage of the great technologies without ruining or omitting the social aspect of what we do.

Dr Wachter: It's very important, Bob, to not get too nostalgic. There is a tendency for geezers like us to say, "Let's just re-create radiology rounds the way it used to be." Young folks will say, "Why? That's crazy. Why should we go down 10 floors to go look at the film if the film is anywhere?" So, you have to ask, "What are we trying to do?" There is something fundamentally important about an exchange between two human beings about a complex case, if it's a consultant, or about a film, if it's radiology. How do we build that back in, in a way that probably doesn't just echo what we used to do 30 years ago? It may look very different, it may be a digital conversation. Who knows? It may be through Skype. It's an open playing field now, and I think the technology will be part of the solution. The core thing is to say, "What is lost and what's fundamentally important about what's lost, and how do we reenvision it in our new era, given all the new pressures and the new opportunities that the digital tools bring to us?" We have barely scratched the surface of that conversation.

Dr Harrington: I could not agree more that it's not just replacing what we had, but it's about improving on it. Our vice dean for education at Stanford is doing work with the flipped classroom. You and I probably both have memories of half the class sleeping through med school lectures and now what they have said is, "Okay, we all learn at different paces. Watch those lectures at home in 5- to 10-minute snippets and then come to class prepared to engage in problem-solving or in case dissections. If you watch one of these flipped classrooms, the medical students are really problem-solving. Wow, what an improvement on how you and I went to medical school.

Dr Wachter: Yes, it's interesting in many ways. The key is to convince this younger generation (if you need to) of the core values, that communication is important, that engagement of all the parties is important, and then they will teach us. They will say, "Yes, it would be great if we could have a discussion with the radiologist or with the cardiology consultants about this case, but why not do it this new way?" I don't think you and I would ever figure that out. I wrote a book critical of where we are in our technological evolution and people still come up to me and say, "Don't you think we should just pull out the wires and bring back the three-ring binders?" I think they are crazy.

Dr Harrington: No. We can't do that.

Dr Wachter: People sometimes say, "Well, couldn't we have bypassed this incredibly clunky stage we find ourselves at now if we had been more clever and gone right to this better place? I'm not sure that was possible either. I think until you implement the technology and say, that's surprising, I'm not sure any of us are smart enough to anticipate all the issues and [provide a prophylaxis] against them.

One of my favorite quotes (and I have this in the book) is from Henry Ford, who reputedly said, "If I had asked people what they wanted, they would have told me faster horses."

None of us are smart enough, and we don't have enough imagination to envision what our life will be like in this new technological environment, but once you are in it, then you have to say, "Well, that's not what I expected, or we've had some major gains, but we have had some really profound losses. How do we deal with that in this new environment?" That's really what want to get at.

Learning from Aviation

Dr Harrington: That comes across. One of the analogies that you make throughout the book, and certainly others have done this as well, is the comparison between healthcare delivery and flying a plane. There were a series of comments that really struck me, Bob, and I am wondering if you can reflect upon them. Whereby the engineers who make planes for pilots to fly are very cognizant of the pilot experience. They don't want to eliminate that pilot experience. Yet, in medicine you have commented in the book that there doesn't seem to be that same attention paid to the doctor, to the nurse, to the advanced practice provider at the front line. It's really just about the machinery. What's different between engineers and hospital administrators?

Dr Wachter: I am not sure it's engineers vs hospital administrators, because in some ways the more relevant comparison is the engineers at Boeing and the engineers at Epic or at Cerner, because both of them are developing IT tools and systems designed to make the work better and safer. They have the same job in many ways. I interviewed Captain Sullenberger, who landed the plane on the Hudson River. He is a remarkable guy. We were talking about the Air France flight that crashed off the coast of Brazil several years ago. He suggested that I go up to Boeing and spend a day with the engineers there. A few calls from Sully, and the next thing I knew, I was sitting in a Triple 7 simulator, which was just a remarkable experience, and talking to the chief engineers of Boeing's cockpits.

What was so impressive to me was a major cultural difference between what I heard from them and what I heard from technology, engineers, and vendors in the healthcare space. The ones in healthcare are really smart people trying to do the right thing, but they are very, very distant from the delivery of care. In their heart of hearts they think they are doing the right thing. They think the doctors and nurses are important cogs in the system, but they see us mainly as technophobic obstacles. They are designing their systems not only for us, but also for the people doing the billing, the people doing the malpractice prevention, and the people doing quality measurement, so they have a really hard job on two levels: One is the multiplicity of audience and stakeholders they are trying to satisfy, and, of course, by doing that they satisfy none of them. The second is, Epic does not run a hospital, Cerner does not run a hospital, so it's very hard for them to actually understand what their tools do in the real-life practice of medicine for a primary-care doc in the office or one of us running around the hospital. They have to get out of the office and see it in a very different way.

All Boeing engineers are trying to do is build a system that safely gets your plane from San Francisco to JFK, and that's it. They are not thinking about billing, they are not thinking about malpractice, they are thinking about doing this one thing safely and that makes their job much more straightforward. The difference in culture is more important; when I asked them if they do user testing and watch the pilots using their machines before they sent them out into nature, they said, "Of course we do that. We wouldn't dream of developing a cockpit computer without watching the pilots use it for thousands of hours. Because we are not smart enough to get it right all the time. We are going to think that this will work a certain way, and we watch the pilots and say, 'Well, I didn't guess that they would do that.'" That's just part of their philosophy.

What was even richer was, they said things like, "We have a deep, deep reverence for the pilots, their tradition, and their history, and we know people have died to give us these lessons." There was a part of it that almost sounded like a Hallmark card, but it was very real. I think it leads them to approach their work in building a user-centered design not as something to mark off on a checklist (yes, we watched what happens when the doctors use the system), but rather as a core philosophy of what they are trying to do. I don't think that has happened in healthcare, and, as I say, it's harder to do in healthcare because of the multiplicity of interests and because of the complexity, and because Epic does not run a hospital.

Training for Modern Medicine

Dr Harrington: Well said. Let me focus on the education issue. First maybe, comment on what we should do about our current crop of doctors, people like you and me who grew up in a different age. Yes, some of us wax nostalgic, but some of us just want to get through the day and get our job done. What kind of education or tools can we give the current doc? Then we will turn our attention to the next generation.

Dr Wachter: Well, I think that for many current docs they are going through a huge amount of disruption, and electronic health records and digitalization of their profession is only a small part of it. As I think about the world, I see twin pillars of the digitization of healthcare and the value pressure, both of which changed the ballgame for people that have been practicing for many years, and for folks that had it good in the old days and liked their profession and liked their autonomy, it's hard. We have to be sympathetic to the plight of the modern physician, but not too sympathetic because we also have to recognize that as wonderful as it might have been to have been Marcus Welby, there is good evidence that the quality of the care we delivered wasn't all that good, and the costs were bankrupting the country, and patients were often not satisfied. We can't just say, "Let's turn the clock back 30 years." We have to improve, and doctors have to learn how to use the technology.

One of the faults is in the technology saying, "Can a 60-year-old doctor learn to use OpenTable or Uber?" That's a laughable question. Of course, they can, they use it all the time because the technology is so good. The fact that some older doctors are struggling with technology is not a design flaw in the people, it's a design flaw in the technology. It has got to get better, and I think it will.

Dr Harrington: I think about this every day when I see my 80-year-old mother-in-law online and on Facebook talking with her grandchildren and looking at pictures, contributing to the conversation. You are absolutely right, it's not the person.

Dr Wachter: If we get the technology right, I think anybody can use it. We will, eventually, but we haven't yet, and that is a flaw, not in the doctors, but in the technology and in others.

Medical Students: Hope for the Future

Dr Harrington: Bob, let's talk about the next generation. Are we doing the right things in medical school and during medical training? Maybe I will divide it into two issues: Number one: are we teaching them enough about the quantitative sciences, are we teaching them enough about technology and its interfaces, are we teaching them enough about how to communicate appropriately during medical school? And then two: is our apprenticeship model still the best for medical training, or should we be rethinking that paradigm as well? Medical internship looks different from yours and mine in some ways, but in many ways, if you just looked at their schedule, it looks very similar.

Dr Wachter: Yes. Well, these are huge questions. I was at an AMA-sponsored conference where they were talking about the future of medical education and they asked me what they should learn about technology. I said, "It's not Epic 101, it's not how to use the computer." Because they will figure that out on their own, it's going to be so core to their clinical rotations. I think it really is using data in new ways, communicating in new ways, learning about innovation in new ways because the young people don't have a preexisting view of what medicine needs to look like. They will come in and they will say, "Here are the values of what we are trying to achieve." Let's say we are trying to produce a good note because that's the vehicle that we use to communicate with each other and increasingly to communicate with patients (as more patients can read their notes). I think it is going to be the young people who teach us what a good note looks like in the digital era.

People talk about the vendors who have created these templates that are clunky, with check boxes and all that. Well, that's part of it, but I think we need to educate each other about what good communication looks like in the digital era. How do we communicate with radiologists? How do we communicate with patients in the digital era? What we want to give our students is a core set of values and obviously some underlying education about how the technology works, and certainly the rest of medicine has not gone away. They have to learn the core medicine that we had to learn as well. Once armed with those core values, they can reenvision their work in their workplace to make it better. I have great confidence that they will do that.

I tell the story in the book of talking to the medical students at UCSF a year or two ago. I was trying to shake them up, and I said, "You people are going to be under unrelenting pressure to figure out how to deliver high-quality, safe, satisfying care at the lowest possible cost, very different from the world I entered 30 years ago." One of them raised his hand and said, "What exactly were you people trying to do?"

Dr Harrington: Yes, I read that in the book.

Dr Wachter: What we are asking of them (and of all of us) is completely natural to them. They can't relate to us complaining that you have to do it in a digital environment. If we said, "You don't have to do it in a digital environment," they would say, "Are you crazy? Of course we need digital tools. That's how we live our lives." I think they are going to give us more answers than questions. I wouldn't focus too much on the nuances of this piece of technology vs another, it's the bigger-picture issues, how do you use these tools to the betterment of your patients and then how do you innovate and make systems work better that's the core of the education.

Dr Harrington: I wrote in our department newsletter not that long ago that if you are worried about the future of American medicine, meet today's medical students and you won't worry. They are going to get us there because they are bright, talented, and in many ways inspirational. They do think differently from you or me, and that's a good thing.

Bob, I want to thank you for joining me. I want to thank the Medscape listeners for listening in. I have been privileged to have a conversation with Bob Wachter, who is a professor of medicine at UCSF and the author of the New York Times science best-selling book, The Digital Doctor. Bob, thanks for joining us here on theheart.org and Medscape Cardiology.

Dr Wachter: It was really a great pleasure, Bob. Thanks so much.

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