Disclosure: I was given a copy of the book to review by Bob as one of the people quoted within its pages
I finally got to thumb through a paper copy of Bob Wachter, MD’s (@Bob_Wachter) book about a month ago, after meeting up with him last summer while he was on the journey to write it, and then I knew I had to read it. I could never have believed when I started the health information technology journey more than (cough) 15 years ago that there would be enough content for a whole book about it. And yet, there is more than enough of a story to be told, and I’ll say, to be told from the physician’s perspective. Why? Read on.
There are several points in the discussion of the technological transformation of health care where we meet people, patients, nurses, doctors, who are not treated gently in the very system that’s supposed to heal them and support them in healing others. This is a problem far greater than one that is intended to be solved with technology. It’s an important thread that I identified with throughout, from the tears shed by the people Bob talks to, to the people I regularly encounter in the human centered design work I get to engage in in 2015.
Health care can be an unnecessarily brutal place. All of the technology in the world isn’t going to fix that. This is why I’ve coined this the decade of the patient. After reading the book, I’d further say that the next revolution in health care will be the human revolution.
I like the way Bob dissects what he sees as a physician writing about physicians.
I had been hearing about scribes from Christine Sinsky, a primary care physician in Dubuque, Iowa, who studies “joy in practice” among primary care physicians. (The CliffsNotes version of her findings: there isn’t much.)
There are stories within of complete ridiculousness in the building of the digital health systems physicians are supposed to use and the way in which protagonists like Christine (who is a well respected physician and champion of innovation) do their best to accommodate to them, rather than the other way around.
Bob is a world renown patient safety expert (this fact came back to me as I dove in) and does a post-mortem on a pretty significant medical error facilitated by poorly designed technology in the context of what I would call the leadership deficient culture of health care.
By leadership deficient, I mean an environment where a system is placed on a pedestal above the people in it, resulting in the subjugation of the basic human need to be able to say that something “just doesn’t look right” to someone you’re working with. In the communication work I do, I’m given full license to send an email with the subject line “JDRL” (‘just doesn’t look right’) any time with the confidence that it will be investigated. That system was not created by a physician, by the way (+1 @VinceGolla), which speaks to leadership needing to be enabled by all leaders in a health system.
This episode still haunts me because of the rage in IT that BYOD (bring your own device) is:
In this hospital, like many others, the electronic record can now be accessed from a tablet or smartphone, as well as a regular computer. The resident began to enter the “discontinue Coumadin” order into her phone when up popped a new text message— she was invited to a party that weekend! By the time she answered the text, the team had moved on to the next patient, and the resident forgot to stop the anticoagulant. The patient suffered an episode of bleeding around the heart that could have been fatal.
Wachter, Robert (2015-04-01). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (p. 84). McGraw-Hill Education. Kindle Edition.
I was floored when I read this
When my patients are able to see my notes (UCSF has not yet rolled out OpenNotes, but is likely to in a few years), I will undoubtedly engage in some self-censorship.
Wachter, Robert (2015-04-01). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (p. 178). McGraw-Hill Education. Kindle Edition.
Wait – a few years? How can a clinician leader say that with a straight face?
Man vs/with Machine
There’s a healthy and complete discussion about something that in my opinion only a few people, likely physicians or nurses, are capable of discussing, which is the total or partial replacement of clinicians as diagnosticians by computers. I trained in the era of “expert systems” which were supposed to replace us, but instead became expensive failures. The challenge stems from people who have never taken care of patients’ irrational exuberance that they can design systems that can take care of patients. Bob explores this personally by going to see the venture capitalist and the humanist physician, both in silicon valley, and luckily decides that the venture capitalist “might not quite get it.”
You can read it yourself and see if you agree. I’m sure there will be entire conferences devoted to this topic (and many already have been), however, I’m going to fall back to the writings of John Berger, circa 1966:
It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.
Contact us when you’ve figured out that problem 🙂 . In all seriousness, though, what comes across throughout is that there are deep human issues in health care that technology is not going to wire around.
And then there’s my quote
I’m honored to be included
Ted Eytan, a family physician who runs Kaiser’s Center for Total Health, is an exuberant supporter of electronic connectivity between patients and the system. “When you start to receive messages from your patients in their own words, it’s a totally different experience,” he said. “From day one, I had patients e-mailing me about sexual issues that they never would talk to me about directly. Once you do it, it’s the thing.”
Wachter, Robert (2015-04-01). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (p. 184). McGraw-Hill Education. Kindle Edition.
For the record, no patient ever emailed me about sexual issues, however, patients did email my colleagues about issues related to their sexual health, which I want to clarify both to protect privacy and for accuracy.
And I am an exuberant supporter of connectivity between patient/doctor/nurse/clinician, and of technology in health care in the setting of strong leadership. I am speaking of the “healer, leader, partner” model that is in place in Kaiser Permanente, where Permanente physicians guide the delivery of care in partnership with business leaders to make sure things work for themselves, but most importantly for the people we serve.
Case in point:
#outsidein Loftus: "Make sure there's a close dialogue – physicians are connected to people who can fix things fast" @KPMidAtlantic
— Ted Eytan, MD, MS, MPH (@tedeytan) April 29, 2015
And she (Bernadette Loftus, MD, The Associate Executive Medical Director of Kaiser Permanente Mid-Atlantic Permanente Medical Group) is right. In many cases the people who can fix things fast are physicians (or nurses) themselves (always remember, the #1 user of an electronic health record system in the health care system is a nurse, in the community, it’s the patient).
Bob calls himself a “typical electronically overendowed American” in the Preface. He is far from typical.
I met him in 2008, probably the only other physician I met at that time that knew what a blog was, much less was writing one. I came to find out in the pages within that he was the program director for the Sixth International Conference on AIDS, held in San Francisco in June 1990. I could have easily (and would still like to) spend an hour (or 10) talking with him about that experience alone, one of many in his portfolio of innovation, including leadership in the hospitalist movement and patient safety as I mentioned above.
He has the cred of a great physician who’s worked with the most terrific excellence in medicine, and the most vulnerable, most tragic, and he goes to the places where people are to ask questions and learn. It comes across in the pages, and I appreciate it. Like I said, cred.
I’ve encountered people who have read the book, and I’ve found myself recommending that others encounter it, too, because we’re all here to do something wonderful for the people who need us and we have to know where we came from to know where we’re going. See what you think, comments welcome to me, or to Bob, he’s easy to find @Bob_Wachter . I love technology for that 🙂 .