Author, and killing a king comes out in october of 2015. This was a quick preview on booktv on cspan2. Dr. Robert wachter of the university of california at San Francisco talks about the impact of the digital revolution on the medical field and discusses if the hype surrounding it is warranted. Dr. Wachter argues that while the ability to keep electronic records is a largely positive development, using computers to deliver care which is becoming more common is a step too far. Hes interviewed by dr. Abraham verghese, author of cutting for stone. [inaudible conversations] [inaudible conversations] good evening welcome. Were so pleased to welcome our speaker tonight dr. Robert back or who will be wachter who will be in conversation about his new book, the digital doctor. His book is available for sale up front and hell be signing after the reading tonight. And he will be in conversation tonight with author educator and physician dr. Abraham verghese. Some quick housekeeping items. Please silence your cell phones but feel free to take pictures, tweet, Facebook Instagram whatever it is that you do to make your friends jealous that youre here tonight. Also for q a, please raise your hand, and ill come over with the microphone. Since cspans booktv is taping tonight, we want to make sure that your question gets recorded. Im going to briefly introduce abraham, and he will then produce robert. Abraham is an internationallypopular author and a prominent voice in medicine with a uniquely humanistic view of the future of health care. His memoirs and novels on medical themes have sold millions of copies, been translated into many languages and topped bestseller lists while his New York Times articles making the case for greater physician focus on the patient in an era of Technology Advances in medicine, have made waves in the medical community. His novel cutting for stone, was a runaway hit, topping the New York Times bestseller list for over two years and quickly optioned for a movie. The rumor is he is working on a new book which will be released sometime in the next, i think its safe to say, five years okay . [laughter] please help me give a warm welcome to doctors verghese and wachter. [applause] thank you. Thank you so much nicole, for that wonderful introduction. Can you all hear me pretty well . Its such a treat for me to be here with my good friend, bob wachter. In fact, the last time i was here was for someone who bobs very close to, and that is his wife katie for her beautiful book mother, daughter and me. And its a treat to be back now with bob wachter. Ive actually known bob for many years, and weve crossed paths without actually knowing it, bob. When you were a Robert Wood Johnson fellow at stanford i think you were asked to be in charge of the first hiv the first aids conference, and i traveled to it, and i have a very distinct memory of it. It was a very poignant time as you remember thats right. And i remember sitting watching a sitin in the lobby of the marriott or the hyatt and seeing Randy Schultz off to the side looking at this. And his book and the band played on was really the book that got me so committed to the hiv story. Bob trained at the university of pennsylvania. He did his residency at university of california San Francisco. Was a Robert Wood Johnson fellow, as i mentioned and has gone on to really a distinguished career in the field that he invented, so to speak, in a very important article he coined the term hospitallist. And hes surely the leader of the hospitallist movement in america. Its interesting bob i think many times people have pitted us against each other. Im the luddite which i dont think i am no, youre not. I certainly write about the dangers of technology. And i always viewed you as someone who very much embraced technology certainly more than i did. And so this book was a bit of a surprise in the sense that i loved it and youve taken a tack on technology that completely took me by surprise. So id like to begin by just asking you what the motivation was to get you to write book. What happened . First of all, thank you abraham, for doing this. And, yes we go way back. I dont know if you recall, but i reviewed my own country in the new england journal and luckily, i loved it, so [laughter] it helped our friendship along the way. And abraham, of course is my role model as a physicianauthor, so thank you for doing this. Those of us who have been practicing medicine and teaching have been waiting for computers to enter our world for 20 years and computers entered our world the rest of our lives because of our iphones and they were so magical and so transformative that i think it was quite logical to believe that computers would enter medicine and would make everything better. I think particularly for someone like me, my main academic interest for the last 10 or 15 years has been patient safety, so medical mistakes. And i cant tell you the number of mistakes that we analyze at ucsf where we just sat there and said if we just had computers you know . Someone misread the doctor ares hand writer because it was like mine, indesigh for bl, or we didnt realize the patient was allergic to a medicine because it wasnt in the database. So i think the combination of the wonders of computers in the rest of our lay lives and the desire to fix problems we had led us to anticipate this moment for many years. Medicine did not go digital on its own it required 30 billion of federal incentives. But then in a very short period of time, over the last 35 years, it really went analog to digital very quickly. So almost like a tsunami of digitization of the Health Care System, it happened in a very short period of time, and i was shocked by how badly things were going. And those of you who are physicians or nurses know this, that it changed the work in ways that often there were positives to it, but often made it harder and less efficient and screwed up is work up the work flows. And those of you who are patients, youve probably had the experience of going to your doctor and you ask a question, and the doctor you start speaking and, in fact, you coin the phrase the ipatient. So i began wondering why was this so bad . And in the beginning i began pitching stories to my wife katie who writes largely for the New York Times. And then one day at ucsf in a story i tell in the book, we gave a kid a 39fold overdose of a common antibiotic. The dose was supposed to be one pill, and we gave the kid 39 pills. And, luckily he didnt die. But as i listened to the story as it was spooling out during the meeting and it began as a fairly simple error but then alerts were ignored. And then in the old days a technician would have seen an order for 39 pills and said whats this about and would have tapped someone on the shoulder, but that persons now been replaced by a robot. And a young nurse saw an order for 39 pills and said this is really weird, but she said i know to get to me, it must have gone through a computer and a person, and i have my bar code, and she bar codes it and the computer says its the right dose. And she gives the kid 39 pills. Be the equivalent of seeing a speed limit saying the speed is 2500 miles an hour. I just came home that day and i said to my wife, you know, i need to write about this. And katie said quite sagely you must do this journalistically. And i said, what does that mean . [laughter] she said youre going to have to get out and talk to people. And i said, i hate people. And she said, i know that. [laughter] she said, i dont care. The only way youre going to get right is basically doing a charles kuralt, going around the country and talking to vendors and policymakers and doctors and patients. And so thats how i spent the last year, and it was just immensely fascinating. Wonderful. By the way, he is kidding when he says he hates people. I mostly like them. [laughter] im going to get bob to read a section at the very end which i think will prove to you that he far from hates people. Even though that medical mistake is one you talked about with me and as you embarked on this book, i was actually pleasantly surprised to find that you didnt begin the book with that. You sort of began with a completely different anecdote. Yeah. Would you mind sharing that one with us . Yeah. I realized i thought that book might be the core that story might be the core of the book, and i, transfer, didnt want therefore, didnt want it to be the beginningover the end, it wanted it in some ways to be the anchor of the book. The story that i start the book with is the story of a physician, a surgeon at the mayo clinic who i happen to sort of almost by happenstance ran into when i was visiting professor there. Some colleagues said to me theres a surgeon here who switched fields from being a surgeon to being a computer expert. And i said, thats interesting. And my colleague i said, why did he do that . She said, one night when he was on call when he was an intern, just finished medical school, there were four patients who had code blues meaning their heart stopped, within an hour. Now, that might not strike you as weird if you watch tv where that does happen in an hour of e. R. , but i can tell you in 30 years of clinical practice ive never seen that. We at ucsf, we have about 30 code blues a month. So, you know, four in an hour is impossible. Three of the four patients died, and as he came to think about this he recognized that part of the problem was they didnt have Computer Systems that could guide them to do the right thing, and he decided to leave the field of surgery to improve computers in health care. As i was interviewing him and he was telling me the story, he was a big macho guy who was a weight lifting champion in the state of indiana, and hes telling me the story, and he stops and starts crying. And i said boy, this is so profound, the experience he went through. At the end i said, well, you must be thrilled now we finally are computerizing health care because the federal government got involved and put a lot of stimulus money behind it, this must be a great moment for you. And he said, theyre selling us snake oil to. I said, thats interesting to hear someone whos devoted his life to computerization in medicine and is tremendously disappointed. And the reason i started with him was i wanted to point out the tension to people between who are noninsiders between these two worlds of bin clinical clinical clinical medicine and the people that design Computer Systems. And i came to believe part of the problem is those worlds have not morphed together. Theyre operating at distinct siloses, and the groups dont understand each other very well. Matt burton, this surgeon became sort of an icon for this effort to try to bridge the field but hes a rare bird. That was part of it. I wanted to demonstrate to people, i hoped that even though this is a book being written by a doctor about a technical field, i could see how people would say boy, this is going to be stultifyingly boring. And i think the storys not boring, and i wanted people to get the sense that theres a huge amount of drama and part of its funny. It really has some life to it. The characters were really interesting. So that was why i started that way, and it felt like the right way to kind of get into the story and raise some of the key points of tension that i wanted to explore. Theres a section in the process that i think youre planning to read and if you wouldnt mind reading that for us. Sure. While bobs finding the page, i just want to see what a pleasure it is to see so many of you turn out tonight. I want to especially thank keplers. I have a special relationship with keplers because i read here for my own country in 1994, and with every book since then. Never thought that id be living in the neighborhood and be able to basically cycle over, walk over. And so thank you so much for being the host for this. All the folks who work here are like family, and theyre often recommending books to me. Did you find the page . Thank you all for coming. This is incredibly delightful, to have you all here. Yeah. This is part of my, you know, part of the other issues, i wanted to frame my own point of view. And my worry was people would see part of the reason i wrote it was the books that i saw about computers in health care were either highly technical or relentlessly hypey, i thought. Were painting a picture of this Wonderful World that maybe well get to eventually, but it did not feel like it reflected my daytoday reality. And yet i had the feeling someones going to read the subtitle and say this is a luddites creed. And there are people out there who say lets pull out the wires and bring back the threering binders, and we cant do this digital thing. Lets go back to paper and pencil. I think theyre crazy. I mean, we cant do this. We have to make health care digital. Its the only way to get it right. But we have not gotten it right yet. I wanted to frame my own point of view here. And then the last paragraph ill tell you why i wrote about that. While this is a book about the challenges were facing at the dawn of health cares digital age, if youre looking for a dr. Luddite, youve come to the wrong place. Hes over no, hes not over there. [laughter] part of the reason were experiencing so much disappointment is that in the rest of our lives Information Technology is so astonishing. I have no doubt that even in medicine our bumbling adolescence will ultimately mature into a productive adulthood. We just have to make it through this stage without too much carnage. Of course, if you picked up this book look for breathless hyperbole, you wont find that here either. We are late to the digital carnival but there are barkers everywhere telling us that this or that app will transform everything, that the answer to all of health cares ills is being developed even as we speak by a soon to be billionaire something tinkering in a cupertino garage. [laughter] this narrative is seductive some may even be real. But for now despite scattered rays of hope the Digital Transformation of medicine remains more promise than reality. Taking our pulse, counting our steps and reading our moods are pretty nifty, but they arent the change we need. Making this work matters. Talk of interoperability are, federal incentives, bar coding and Machine Learning can make it seem as if health care Information Technology is about, well, the technology. Of course, it is. But from here on out, it is also about the way your baby is delivered, the way your cancer is treated the way you are diagnosed with lupus or reassured that you arent having a heart attack. The way, when it comes down to whether you will live or die you decide and tell the medical system that you do or dont want to be rhesus sated resuscitated. It is also about the way your insurance rates are calculated and the way you figure out whether your doctor is any good and whether you need to see a doctor at all. Starting now and lasting until forever, your health and health care will be determined to a remarkable and somewhat disquieting degree by how well the technology works. That last paragraph did not appear in the press maybe even in the first version that you were nice enough to look at. And our daughter read the preface, and she said this is really good, and its really interesting, and its good writing, but the book doesnt have anything to do with people, and it needs to. And you need to tell folks why this matters. And thats where that paragraph came from, so im very glad for her. Shes greating from graduating from college in a week, and thats why this paragraph is here. Thats wonderful. One of the things [inaudible] sure. One of the things that strikes me is that weve been very privileged to watch this transition, and for many of our younger colleagues who were at a little reception earlier today its always been computerized in a sense. Yeah. And i was stunned by the section in your book where you talked about the shoe box routine. Yes. Where you sort of went through the shoe box looking for lab results. Talk a little bit about that and i have a followup. Yeah. I see some physicians in the audience. Theyll remember this. One of the fun part of the book is people coming up to me and saying oh, yeah, id forgotten about that. And, of course, the young folks have no idea what that was. This was my recollection of my time at the v. A. Hospital in San Francisco when i was an intern and the way we got our Laboratory Results was known as checking the shoe box. The shoe box sat on a card table outside the Clinical Laboratory and all of the lab tests the sodiums and the blood counts and all that, were filed roughly in alphabetical order although not perfectly n a shoe box outside the laboratory. And every day that was part of the ritual. Wed go down there and flip through the shoe box through these flimsy carbon copies i dont know if young people know what a carbon copy is [laughter] but thats what we used to have. And you felt it was a little, tiny miracle if you found all of your patients blood test results. [laughter] so when you grew up with that, how could you not be so excited about the idea that all the Laboratory Results are going to be in the computer, and theyre all going to be graphed and trended and all sorts of wonderful things . I think thats partly why this has been so disappointing, you know . We lived through an era in which we knew that this needed to go i. T. , we knew that the technology could help us do some fundamental things, and thats partly why weve been waiting for it with such baited breath and why its been so disappointing so far. You and i lived in the era where we would go down to radiology and find the xrays and go through the folder and you know, wed never want to relive those days. Yeah. Its so lovely to be anywhere and pull up the image. Yeah. And yet you point out the unexpected consequence of that advance is were not socializing with the radiologists and getting the benefit of that traffic. Talk a little bit about i think that was one of the epiphanies that i had that computers, that theres a tendency to believe that computers just digitize your whole process and you can make it sleeker and you dont have to go through a shoe box, and thats good. Those of you that work in technology and other fields have figured this out but this is all new for us. They change everything about the dynamics of the work and the social relationships and the geography. And the story i tell was the one that just came to mind when i began thinking about this. When i was