Leaders in Medical Education

Dr. Robert Wachter, Professor at the University of California, San Francisco, and Author of The Digital Doctor

Alice Ferng
Sep 3, 2015

Dr. Robert Wachter is Professor and Interim Chair of the Department of Medicine at the University of California, San Francisco, where he somehow finds the time to also direct the 60-physician Division of Hospital Medicine. Dr. Wachter coined the term “hospitalist” in 1996, and is generally considered the father of this specialty. Modern Healthcare magazine has named him one of the 50 most influential physician-executives in the United States, and in 2015, he was first on this list. He is the author of a few hundred articles and of six books, including a book this year titled, "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age," which received stellar reviews and was a New York Times science bestseller. Dr. Wachter has served on many healthcare advisory boards, including Google’s. We are pleased and honored that Dr. Wachter was able to spend some of his valuable time with us and allow us to share this interview with you. His blog can be found at: www.wachtersworld.org

How did you first become interested in medicine? Medical education?

I grew up in Long Island, in a family where neither of my parents went to college. However, there were a fair number of doctors in the neighborhood and between my parents’ interest in medicine and going on rounds with some of these neighbors, I became interested in medicine. It was rich and exciting. For me, the real tension was when I became very interested in policy and in how decisions were made in complex organizations.

When I went to college, I was pre-med but majored in political science. I didn’t really have any idea how I might combine my sense that medicine was the right thing for me, and my interest in how things worked and how systems were designed. It turns out I was very lucky that those kinds of skills and interests were fairly useful as medicine has begun to realize that we need major system re-design, and that policy and politics are very important.

I found the sweet spot between medicine and policy with the help of my teachers and people who mentored me. One of my favorite things about internal medicine was the sense that medical education was a central focus of the discipline. One thing led to another, and I found myself leading UCSF’s medicine residency program in the early 1990s, which was incredibly interesting.

Can you share your background on how you got to where you are right now?

I went to the University of Pennsylvania for medical school, which is also where I went for college. I loved my time during college there, and the medical school was terrific and it was a natural fit to stay there. I got into Penn Med off the waiting list one week before classes began – I already had an apartment in St. Louis and was ready to move there when I got the call that a spot had opened at Penn. It’s funny, you end up in these situations that seem completely pre-ordained in retrospect, but you realize that, but for a funny bounce or two, you could have ended up in a very different place, where your career might have gone in a very different direction.

At Penn Med, I met physicians who didn’t think that my career aspirations and my interests were all that odd. I had an interest in the health care system, how money, ethics and politics influenced care, and yet I was quite sure that I wanted to be a doctor and a teacher. Penn was one of the earliest centers that had physician-professors that thought the way I did. That led me to realize that my interests were not so weird after all and that there might be a path for me.

I came to UCSF for my residency. At the time I was applying for residency there was an airline called Eastern that had a fixed price ticket for $600, which allowed you to fly anywhere in the country for an entire month. Unbelievable! UCSF had the reputation of being one of the best medicine residencies in the country so I figured I would come out and take a look, and if I liked it, it would be my tenth choice. I had absolutely no inclination to move to California.

I came out for interview day, and absolutely fell in love with the place. San Francisco is physically beautiful, of course, but more importantly I was very impressed by the breadth of the training, which was unmatched by other programs I looked at. I also really loved the culture. It seemed like a very high powered residency with very smart and accomplished people, but everyone seemed to be supportive of one another and cared about balance in their life. At the end of the day at interviewing here, I shocked myself by deciding that I wanted to come to San Francisco, and was equally shocked when they accepted me for the residency. I came for what I thought would be 3 years, after which I would move back to the northeast. That was 32 years ago. Again, life has so much serendipity – it’s almost not worth trying to plan things.

At Osmosis, we have worked on something called "The Smartphone Physical", which consists of a set of 9 medical devices that allows us to monitor patient parameters such as weight, vital signs, and ECG. Other devices also include a stethoscope, opthalamoscope, otoscope, spirometer, and ultrasound. Do you see there being an increased use of these devices? What may be the advantages or disadvantages to what you coin as "The Digital Doctor"? 

To me, I think that we have to rethink the whole physical examination in terms of what the ultimate goals are—we are trying to gather data that is useful for patient care. Every finding has test characteristics, in terms of false positives and false negatives, and we need to understand them.

But the exam is more than just another test, like a hematocrit or a CT scan. As Abraham Verghese has written about so eloquently, the exam also bonds us to the patient and it demonstrates through touch that we care about them.

There’s a long tradition of skepticism about new technologies. One of my favorite quotes comes from the 1834 London Times about this horrible thing called a stethoscope that was going to ruin medicine.

“That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”

We sometimes have interesting and often negative reactions towards newer technology tools. I’m quite certain the stethoscope will eventually be replaced by a tool that can actually look inside the heart – like an ultrasound or maybe even something better. We have to be careful not to be “wow-ed” by the shiny penny, just because it’s a new gizmo that gives you pretty pictures. We should instead ask ourselves: “What use does it have?” and “Is it better and cheaper and better than what exists today?”

The idea that you can have everything in one package is very exciting in the same way that my smartphone has now not only replaced my phone, but also my computer, my iPod, and my camera. The idea that you can carry around one thing and that it not only replaces some parts of the physical exam, but also integrates with the electronic health record and therefore provides you computerized decision support, that’s pretty great. Imagine that the device says: “in this type of patient, with this finding, this image or sound tends to mean x or y.” This doesn’t exist yet but I think it will. It strikes me that the technology should not only deliver to us new pieces of data in new ways, but also integrate data in ways to help us make better decisions.

Right now we think of an otoscope or stethoscope as providing some piece of auditory or visual data that we process to try to figure out what it means. But you can easily envision a smartphone application that collects similar data but also has embedded in it decision support or a knowledge base that can be utilized to aid clinicians in their work.

Do you think there will be a shift of medicine that results in “de-skilled” residents and students as a result of these devices?

Of course. There is some natural de-skilling that is probably fine—I don’t know how to use an abacus anymore and I can’t remember my wife’s phone number, and I don’t know how to drive anywhere if my GPS goes on the fritz. I don’t remember anything as well as I used to, because I know I can Google everything. So there’s a part of de-skilling that is perfectly natural. The trick is: where is it fine and where is it harmful? Sometimes the computer may give you wrong answers or you will have to contextualize the answers, and to know when to take over the controls.

For example, modern airplanes spend most of their time running on autopilot. This creates a risk of complacency, when the pilot just relies on the computer to fly the plane. But if there is a malfunction with the computer and the pilot does not know how to manually fly the plane—that would be a big problem. We've seen several airplane crashes whose root cause was precisely this. The same applies to medicine. If the computers were perfect and could provide the necessary care, then we would all be out of jobs. In that case, our skills could be used for another job. But that’s not going to happen in my lifetime in most of medicine, and, in certain areas, not even during yours.

So the real issue is: what do you do in areas where the computers are pretty good most of the time, but periodically, they lead you astray. Or the computers are doing the job most of the time, but it’s still important for the human operator to be awake. Those cases pose both interesting and challenging educational design issues that we have just begun to confront.

As a teacher, are there any changes you’ve made due to the increased reliance on mobile devices?

As a teacher on the wards, I mostly just focus on teaching the skills that students need to be effective in their roles as physicians. If I believe that they are becoming over-reliant on the technology to the detriment of the interaction of patients or their degree of engagement, then I would give feedback and try to help them understand why doing more of this or less of that is a good idea. But it’s just as likely that there is a piece of technology that might be helpful that they are not using. So I come into this without a bias that they need more or less technology. I think there are times where technology will be better. The trick is to be using the right tool at the right time. Sometimes, the tool will be computerized decision support. Other times, it will be sitting by the patient’s bedside holding her hand.

I always worry when people get far out on the spectrum one way or the other. I wrote The Digital Doctor partly because there was too much hype out there about wonderful technology that was going to replace everything, and patients were going to be able to completely be able to take care of themselves. But that didn’t feel like the state of the world that I was seeing.

Yet there are people who go to the other extreme, saying that we should pull out all of the wires and bring back the 3-ring binders and clipboards. I think they’re crazy. We should use technology in ways that it helps us deliver the best care at the lowest cost, and be careful that we are not screwing up the human dimensions of medicine, nor falling asleep at the switch, or creating a level of deskilling that ultimately is going to be harmful to patients.

What do you think about all of the recent hype in new technologies in medicine? How do you think the increase on digital devices will shift the practice of medicine in the next decade or two? 

When there’s overhyping, you have to look at whether or not there’s a company behind it – a company with a financial interest in getting everybody breathless over their new gizmo. But not all techno-optimism is destructive or even biased. There is often a perspective that lays out a future vision. It might be optimistic, but it can be useful, particularly as we are trying to navigate today’s current system, which is so problematic and demoralizing. As for the ‘pull-out-the-wires’ types, I get that too. There are days where it feels like technology has set us back in some fundamental ways, so their arguments are important to listen to.

In the same way that people can romanticize the future state that’s not here, they can also romanticize a past that really wasn’t all that good. Nostalgia is a very powerful force and people often airbrush out all of the bad stuff. Do we really want someone to decipher my handwriting and figure out what medication I was trying to order? Do we really want to go back to a place where I can’t read or write a note in the medical record from home? Or I can’t read an X-ray from home? Do we really want patients to have to go to the hospital medical records department to order their records – and be told it’ll take a month. There are so many logical arguments to move in the direction of a digital health care system. We just have to be more thoughtful about it.

What I learned most from researching and writing my book was that we can get there, and we will get there. But the angst today is typical of the industries that undergo technological transformation – the common pattern is that it is overhyped and there is widespread disappointment in the early years. A few years into it, people ask: “what happened, why isn’t it working the way everyone said it would?” And then, 5 to 10 years later, things start to get better. This is partly because technology gets better, but much more because younger people come in and say, “Why the hell are we doing this thing this way?” And the answer is that we always did things this way. When we computerized, we just digitized the old process made it a little faster. But if it was a dumb way to do it and now it’s a faster dumb way to do it, you don’t make much progress. Young folks come in and say that’s crazy, let’s do it a different way! Then ultimately the system remakes itself in a much more thoughtful way, which is when you start seeing the massive gains. We are going to begin seeing that in the next few years.

What are changes you would like to see in the current medical education system? Healthcare system?

UCSF is participating in a national effort sponsored by the AMA to rethink medical education. One aspect they asked me to speak about recently was: what changes should there be to medical education? The first thing I said was that I wouldn’t overemphasize the actual use of the technology, because you’ll learn how to use the computer system when you work at the hospital or clinic. And most young people have such a deep understanding of technology that they don’t need much handholding. It’s much more about understanding the environment that medicine finds itself in now with intense pressure to figure out how do we give better, safer, more satisfying care at a lower cost. That’s what we should be emphasizing: how to we improve our system to deliver higher value, using digital tools when they are appropriate.

I think that technology should be seen as part of the toolkit that residents and others have to improve value. In that context, people have to learn more about human factors, and technology-to-human interfaces, and about what is under the hood of their electronic systems.

But it’s really much more about how to think about the system that I’m working in. How do I understand the new role that I have as a physician, which is no longer to be the lone ranger taking care of individual patients, but now includes, How do I make the system I work with work better? Then, within that context, physicians need to understand the role of technology as an enabler. Some of the time, technology is just the thing that will help me meet the goal of better, more efficient care. But at other times, we also need to understand when technology is not the answer and there are other tools that we need to employ.