The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.
I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.
Dr. Jeffrey Benabio
At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.
Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.
Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?
To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?
Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.
The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.
This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.
As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?