At MedTech Boston, we spend a lot of time writing about the potential benefits of integrating technology into healthcare, but transitioning to the digital age, although imminent, has not been without its missteps. We recently spoke with University of California at San Francisco’s Dr. Robert Wachter about his book The Digital Doctor; Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, and the challenges many doctors face as they integrate technology into their practice.
To hear more from Dr. Wachter catch his Keynote at the Health 2.0 Fall Conference taking place October 4 through Oct. 7 in Santa Clara, Cal.
What inspired you to write the book?
Disappointment. I had been so looking forward to medicine going digital because what we’re trying to do is take care of sick people using information—not only the information about individual patients but also information from medical literature. I study medical mistakes, and I can’t tell you the number of mistakes over the past 20 years that I’ve heard, “If we just had computers this wouldn’t have happened.”
When computers entered the world of medicine they achieved some of the promised benefits—but we also started seeing all sorts of side effects. Everything from doctors and patients no longer looking each other in the eye, to all kinds of medical mistakes, and I realized that nobody was talking about that. I think that the things I was reading about computers in medicine were either too technical or were kind of relentlessly high-end. Really, it was mostly for me to understand for myself why things seemed to have gone off the rails. My hope was that I would be able to explain it to others in a way that was meaningful and would help generate a conversation so we could make it better.
The story of Pablo Garcia is central to your book – can you talk about how this anecdote encapsulates some of the major problems facing healthcare in the digital age?
It’s a remarkable story about a kid at one of the top hospitals in the United States, my own, who was supposed to get one pill and we managed to give him 39, in a completely digital environment with the best computer system in healthcare that a few hundred million dollars can buy.
When I first heard that story, I was in a meeting at our hospital discussing the error. My jaw just dropped lower and lower and lower, because I came to realize that the combination of clunky interfaces, a lack of user-centered design and the fundamental change in the way work is done when computers enter the world of healthcare led to a situation in which what should have been a completely simple, straightforward, ho-hum order turned into something potentially deadly.
Harvard Professor Ron Heifetz talks about technical vs. adaptive change. Technical change is pretty straightforward—you follow the cookbook and you get it done. Adaptive change is something so complex that you have to deeply understand the people and the work and the culture—if you simplify it too much and insert, lets say, a piece of technology, you really will get it wrong in a fundamental way. I think in some ways that error taught me that we had mistakenly treated computerization in healthcare as a technical change, and in many ways it is the mother of all adaptive changes.
At the end of hearing that case I went up to a risk manager. I said to her, “This case has so many remarkable lessons, I think we should disseminate it.” To her credit and actually to the entire institution’s credit—ultimately that had to be approved by our CEO—in an act of what I consider organizational bravery they came to believe that being open and honest about this was the right thing to do.
In taking care of sick patients there’s a lot of very nuanced information that really does still require people to talk to one another. Let’s take the first piece, the doctor patient relationship. An increasing number of patients can recount the story of going in to see their doctor and it appears that the doctor is taking care of their computer and not the patient. The doctor is not making eye contact anymore.
The fastest growing profession in medicine is a field called scribes, young people hired to feed the computer so the doctor can look the patient in the eye again. None of us anticipated that, but computers have turned doctors and nurses into very expensive data entry clerks. So in some ways that’s the most obvious way that computers have gotten in the way of person-to-person communication.
I describe in the book the case of misdiagnosis of Ebola that occurred in Dallas about a year and a half ago. That to me was a perfect example of doctor-nurse communication. The nurse saw the patient in the triage area of the emergency room in Dallas, the patient told the nurse that the patient had a fever. The nurse asked whether the patient had traveled to an Ebola region, in this case Libera, and the patient said “yes.” I believe in the old days that nurse would have walked ten feet, tapped the doctor on the shoulder and said “doc, take a look at the patient in room four, he’s got a really high fever and he’s just back from Liberia.” Today, the nurse types and clicks into her electronic record the facts, and never taps the doctor on the shoulder.
When I was a medical student in some ways the center of the hospital was the chest room in the radiology department, because every day the medical and surgical teams would go down there to see their x-rays. When we did there was a radiologist in front of that board and we would have a discussion about every single patient, looking at the x-ray.
The minute that radiology went digital, something wonderful happened—there no longer was one film. In many ways it is great. But about five minutes after the x-rays went digital we stopped going down to the radiology department because we no longer needed to. I think if you ask old timers like me, and you ask radiologists who remember those days, we all lament the loss of those rounds. And that’s not just nostalgia; there was something very important about that information exchange that now no longer occurs.
Having lived through the digital transition, none of us gave this a moment’s thought. It wasn’t like we anticipated that this is going to be the end of radiology rounds, that we weren’t going to be able to look patients in the eye. It just happened. Nobody anticipated, nobody thought about its consequences, and if we’re going to make it better we have to see how we can bring back the fundamental parts of these old relationships that, to me, were vitally important.
You spend a good deal of time comparing the experiences of physicians and pilots. What are some of the ways in which companies like Boeing have more successfully integrated new technology into the daily lives of pilots, and what can we learn from them?
It’s been a long-standing theme in the field of patient safety. We try to learn from aviation because aviation is a complicated field that does what they do unbelievably safely and reliably and medicine typically does not. Those analogies, I think, are very helpful but sometimes limited because the work of the pilot is very, very different from the work of the doctor. The pilot climbs into the seat and closes the door and it’s just he or she and their technology for the next five hours. Medicine is much messier.
That said, I think there are some profound lessons and as I explore the world of computerization I thought this was an important area to explore. I interviewed Captain Sullenberger, the captain who landed on the Hudson—that was wonderful—and spent a day at Boeing headquarters seeing how they do computer design in the cockpit.
What I learned is that the philosophy of cockpit digitization is much more attentive to the experience and the needs of the end-user, in their case the pilot and in our case the doctor or the nurse. Very smart engineers say “Okay, let’s go ahead and put in an alert or an alarm to tell the pilot that something appears to be a little bit off kilter in the plane.” But before they would ever dream of taking those changes into the cockpit design, they will spend thousands of hours seeing the effects in simulators and in test flights.
That kind of deep degree of thoughtfulness and attentiveness to the experience of the end-user is a fundamental part of the DNA of computer design in aviation and is woefully lacking in healthcare.