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 a medical student at the university of pennsylvania, there was no question in my mind that the central hub of the hospital was the chest reading room, the room where the radiologist read your chest xrays. And the reason i say that is because every day every single team the medical and surgical teams, came through that chest reading room like cars coming through a car wash, one after another. And the radiologist was seated in front of a board that had all the xrays hanging on it. And hed ask what team you were on and hed push a little butt done the button, and the thing would go around and it had these things on it called films. [laughter] some of the stanford chief residents, they dont know what that is. There was only one copy of the film. And we had the radiologists report, but there was something magic in that interaction because the radiologist would say tell me the story. And youd say this is a 46yearold woman with lupus who comes in with shortness of breath. And the radiologist would say oh, if thats the story then this looks like tuberculosis or thats not what the formal reading on the paper said, but it was from this interaction. We learned from each other. They learned from us, we learned from them. Now, about 15 years ago radiology went digital and money before the rest of medicine because now when we got a film, a chest xray with two images, it was now a cat scan or mri with 100. So the cost of printing all those out became exorbitant, and in the year 2000, radiology went digital. Thats all fine, and as you say, its better. We can see it anywhere, i can see it at home, you can zoom in, look at different views. Its all wonderful. But the minute that happened, those rounds ended. Nobody predicted they would end, nobody said they should end nobody wanted them to end, but they ended unambiguously everywhere. And the reason they ended was we no longer had to go to radiology to look at the film. There was no more film, there was the image and it was ubiquitous, and so we stopped doing it. So that magical interaction between the clinician and the radiologist went away, i think, to the detriment of both. In fact, a story i tell in the book, theres a radiologist named paul chang at the university of chicago whos one of the pioneers in digital radiology. He kind of invented the system. And paul changs father was also a radiologist. And you would think if you were a radiologist your son goes into your field youd be proud, and your son was really one of the innovators in the field, really was responsible for the transformation of radiology going digital. You would think his father would be incredibly proud of him. His fathers nickname for his famous son is the man who ruined radiology. [laughter] because the radiologists are actually quite unhappy about this because theyre like the maytag repairman theyre just sitting there reading image after image after image in this sterile environment, divorced from clinical care, and theyre lonely and actually feeling like im not connected anywhere. And then all anymore. And then all other sorts of stuff happens. If i dont have to go to the raid youll department, why do i care if its in my building . The average radiologist in india makes about 40,000 a year, are they really ten times better . Thats an irrelevant world. Its a flat question when youre talking about the film, because its in your radiology department. Its a very relevant question when the film goes digital. Power relationships communications, you know, geography, rounding, all of those things nobody thought thats what computerization was about, but that is precisely whats happened, and its in some ways an unintended side effect, but its very, very real. Another thing weve talked about was i would never want to go back to the days of trying to hunt the old charts, you know, dusty old volumes, and someone had checked them out in their office, and they were gone on vacation. It was a nightmare. So computerizing that seemed like marvelous. And yet as you and i discovered, the computerized medical record is very different from the handwritten one yes. In more ways than just the way the day was recorded. The anecdote that struck me in the book was about the former editor of the new england journal of medicine and, you know when he was ill and in a rehab hospital, he was struck by the fact that the medical record which i guess he managed to see had major, you know dialogue and discussions about his [inaudible] but very little about him. Talk about that, if you would. In many ways the medical record has been more like nonfiction to fiction in part because people now are just checking boxes not really thinking very much. And he found in the medical record there was a lot of stuff that never happened because its copied and pasted from another days note. And then i think the point youve made so eloquently is that people were paying more attention to the record than they were paying attention to him as a human being. And, you know, part of the story i tell is i was saying that, you know if bud was my patient this was one of the heroes of american medicine, the editor of the new england journal of medicine during the year we try figured out how to treat and prevent heart attacks you would think if you were a doctor, youd want to pull up a chair and talk with this guy. It never happened. The relationships withered, and the record has become this Christmas Tree on which were happening about ten different ornaments. Part of what i came to learn was i sort of recounted the history of the record, how did it get to be this way. And its easy to sort of be unhappy with the vendors, you know . Why did they create the system that creates such an unwieldy record. But the vendors are just making something happen that had to happen. The real problem is the doctors note now has to serve so many masters. Its, yes, the patients story, but thats a minor, thats a minor character in the record. Its how we send a bill off its how we prevent from being sue ised its how somebody whos measuring whether were good doctors figures it out. So its become this calamity of checking boxes and copy and pasting things. One of the best stories i heard was an intensive care doctor told me a story of taking care of a very sick patient in the icu. And he picked up he went to the computer and looked at the record, and the record had 20 or 25 pages of gibberish, copy and pasted notes copy and pasted lab results xrays and just filled with data without any meaning whatsoever. What he wanted to know, what the story was, what was going on with his patient. And then so he said let me check yesterdays note, and it was just as bad. His only solution that he could come up with to try to figure out what was going on was he printed out todays note, 20 pages. He printed out yesterdays notes, 20 pages he head them up against the window to see if he could identify a new paragraph. That was what he read. Thats not the way it used to be partly because writing is so painful, you would never write that much. You actually had to sort of distill it down. But it also felt like we were paying more attention to the patient as a person, and the computer has distracted us from this in ways that i think are quite harmful. I think theres actually something more sinister about this than, you know, than i realized. I see one of my former students and your resident, blake charlton, in the back of the room. And he and i have just are published a piece in the mesh journal of medicine is, rather they accepted it and its about a kind of medical error that the chart doesnt describe. And we asked physicians to tell us about instances they knew of where someone had missed something on the exam that led to a consequence and we collected about 208 such anecdotes. Tricia the type you dont see in the United States. How this epidemic emerged, probably some consultants came in and said you know what . All these patients who appeared to be malnourished maybe they have a low protein level, thin and not eating well. If we come up with an algorithm that says malnourished and low protein level lets call thatmedicare will pay an extra 50 a pop. Sounded clever until the epidemic kind of started talking to each other, never seen that in the United States . I dont think so. The hospitals both said it was a, quote, computer error. They repaid the money. That is only a piece of what i think is going on, one of the things that is exciting is 5 million patients in the United States can read their doctors notes. That is an exciting development, patients at right to see their doctors notes since 1996 but march into a paper hospital and say i want a copy of my record which is 300 or 3,000 papers, they will say it will be 0. 50 a page to photocopy. Quince it is digital all you need is a password. That is a healthy trend. What we have seen so far as patients can use it, not overly bothered were scared by it, we have to clean up our language little bit, we sometimes use abbreviations like the patient is s o b for shortness of breath, we have to be careful about that. We see patients say it says here the doctor listened to my aunt lungs and heart and i dont recall the doctor taking a stethoscope out of his or her pocket. You might say the doctors committing fraud, that is terrible, yes it is but it is this sort of relentless system pushing everybody to just document a bunch of facts completely dissociated from the purpose of what we are trying to do and that is why your work is so important because it frames it appropriately in medical terms, lets think about what were trying to do and what its purpose is and computers distracted us from that. In san antonio you use the airline analogy and you have been associated with the field of studying medical mistakes for some time but i was impressed with another medical airline analogy about Southwest Airlines flight dispatcher. Talk about that you dont mind. At brandeis university, she studies something called Relational Coordination and that means the degree to which complex organizations make sense of really complicated fastmoving situations. For her phd thesis she studied a number of airlines and the way they did plane turn arounds, what happens when your plane gets to the airport and parks and they have to turn it around to take off again in 30 minutes. Turns out to be an extraordinarily complex thing like a pit stop crew a few think of the moving pieces to clean and gas and get the food on or no food, you know what i mean. When she came in her bias was the airlines like american and united, did it in a very systematic computerized way, probably had it right and the way those airlines did it is there would be somebody sitting miles away at the air Traffic Control center for this process to have a bunch of checklists and said okay flight 296 they got the food, the gas, it is good, and ready to go. En Southwest Airlines which was fairly new at the time and they didnt do it that way at all. There was a guy on the ground with a walkietalkie running around talking to people, yelling at people and she said that didnt seem nearly as efficient as having one person managed 10 flights simultaneously with the checklist and yet no question in her mind that it worked better and was more efficient, southwest get their planes turned around better and she said theres something about the relationship between all the people and somebody managing it bringing them together, figuring out what is going on so when someone is not doing their job talking to them sternly, cajoling, whatever it takes, you simply cannot do when you are doing it digitally added distance and i think that is part of what were seeing that the computers have driven us as the rest of our lives, look how kids talk to each other through facebook rather than to each other has driven all of us into our silos, our bunkers where we hang out by ourselves or members of our own tribe and so much medicine is like turning around plane around where somebody has to talk to each other and make sense of complex situations and Computers Made that worse. I want to make sure we have time for the audience to ask questions. I was actually very taken with a hopeful note you strike towards the end of the book because it is possible to be in this life we are in right now and imagine it will always be this way. The perspective is here. I thank you for that. Share with us if you will that last section of the book where you have a sort of utopian vision of what hospital might be like and it is pertinent to those of us at stanford because we have scaffolding all over the place and a brandnew hospital coming up. If you guys cant fix this i dont know who can. I came into the book from a position of disappointment and a little bit of anger and i finish the process of interviewing 90 or 95 people much more hopeful and optimistic than i thought i was going to be which was delightful but i didnt fake it. The reason was when i spoke to all these people and asked for hard questions will computers replace doctors or the big i key vendors, are they ok, is Government Intervention go bad . Very different answers but when i asked what does this look like when the dust settles everybody sort of gave the same answer, patients are at home monitoring themselves not the salinas of sensors in your underwear monitoring your heart rate every two seconds in ways that completely non useful as far as i can tell that are being relentlessly overgetting ways that for a diabetic knowing your sugar all the time and going to somebody who is helping to manage your diabetes, probably not a director, probably a coach of some sort, when you visit your doctor is probably a you dont have to go to the office. The patients facing i t tools, linking to the hospital i t tools, reasonable Patient Portal for them to do a lot of their work and i said i could see how we get there and the question of getting there to me hinges not on the technology. It hinges on the choice is we make social relationships, political decisions, the way the money flows and that is not unusual. There is a concept in the i t literature known as the productivity paradox and what it says is every industry has this experience, bring in computers and expect in two years it will make everything better more efficient, making faster and better zippers whatever it is and nothing has happened or it has gotten worse and in five, ten, all of a sudden it starts Getting Better and it is not because the technology has gotten better it is because people every imaginable work and built it around the Digital Infrastructure and you might say we are so late in the game why didnt we imagine the work before hand and save some time here . Nobody is smart enough to do that. It turns out you cannot figure this out until you are working with these tools, banging your head against the wall struggling and henry fords was reputed to have set of i ask people what they really wanted they would have said faster horses. None of us have the ability to understand what this world looks like an joy we are in this world and that is where we are. I can see how we get to a much better place, dont think it is in two years or five years, i think it is a 10 or 15 year struggle but i think when we get there it will be pretty neat. We ran out of stones. I just heard that yesterday. Should use that in the title of the book. This portion of it, this is actually the end of the book. I hate to give away the end, spoiler on alert. High wanted to end the book that meanders from political medicine or policy to the role of patients, sensors, Silicon Valley chapter, pretty broad swath of the world. I wanted to bring it back to the patient and in some ways you inspired me to do this. I felt i needed to bring it back to the essence of what were trying to do so that is why i wrote this ending. A couple years ago i was caring for patients in the 70s, lets call him mr. Gordon. In the intensive care unit. This was a challenging case. It was clinically obvious the patient had widely metastatic cancer was going to die, several members of the family had not come to terms with this sad reality. On top of that i sensed significant conflict within the family. The patients son and daughter were cool toward each other, nearly business like and the son and daughters husband could hardly stand to be in the same room. As mr. Gordon drifted in and out of consciousness i sat with a family in a Conference Room just outside, the family tension gave the redmen have the air, smog of longstanding resentment. I described the clinical situation, told the house it was felt we were sure that mr. Gordon was dying. I gave them my assessment ongoing aggressive care would be futile and inhumane. I recounted mike conversations with the oncologist and Palliative Care team all of whom endorsed my prognosis and approach. I told the my understood their desire to keep mr. Gordon alive but that i believed the time had come to stop trying. After talking for a while the family members began to describe some happy memories of their times with mr. Gordon and recalled his attitudes about end of light care. It became clear he would not have wanted aggressive care at this stage. I could feel family members casting aside their grievances if only temporarily as they coalesced around mr. Gordons interests. Their questions answered i left the room and returned to the i see you. A few minutes later mr. Gordons son Holding Back Tears found me and told me the family had decided that it was time to allow his dad to die peacefully. I replied i understood how wrenching this decision was but it was the right one that i would make for one of my own parents. He went back to the waiting room to rejoin his family. I entered mr. Gourd mastermind inform the nurse we would be switching for our current fullcourt press to comfort care. I asked him to turn down the oxygen on a mechanical ventilator, remove the ivs except for morphine and brought some shares to allow the family to be at mr. Gordons bedside during his final minutes. I walked out to the reading room to inform the family had time had come and escorted them in to see mr. Gordon for the last time. Won by one two siblings embrace, a knotted at each other and act i interpreted as a momentary truce and surrounding the patients bed, mr. Gordon way still, now unconscious from his morphine drip. The stage was set but then i noticed a problem. In his haste to discontinue the various tubes and treatments the nurse had forgotten to disconnect the bedside cardiac monitor which continued to flicker above mr. Gordons head. So it was that at one of lifes most profound moments, nearly impossible in its mystery and poignancy the paradoxically rich with promise and in edibles at this, all four family members eyes were raised, not searching for truth or god but watching little squiggles, the electronic signature of a heartbeat march across the let rectangular screen. Mr. Gordons and was sitting close to the monitor. I put my hand on his shoulder. Speaking to all of the my said your dad is comfortable and i am so glad you could all be here with him. I am sure we is too. But and i pointed to the heart monitor, there is absolutely nothing on this screen that matters. And i pressed the off button. As the screen went black, the family members shared a look of shock and clarity and then what was it . Acceptance, warm, gratitude, transcendence, maybe even law. They turned to mr. Gordon, squeezed his hand, stroked his arm, touched his cheek. The scene was pure, peaceful and in a way that is hard to describe, quite beautiful. And then he died. We have time for some questions now. Thank you for that review of your book. One of the most important aspects of physician relationships is trust. Show how computers intervene and dissociate, trusts by making the hands on interpersonal communication, no longer a major factor in the examination. The medical team in the future that brings that trust hands on questioning, interpersonal relationship back into this . That is a profound and important question and none of us know for sure because we talked about this many times, there are aspects of the hands on portion of the relationship that are probably too inefficient to survive and by that i mean the 20 minutes or so it may take to gather all the history. There are probably parts that the patient can or should do with themselves with a good online tool that guides them through the process. There are parts that are extraordinarily important but we have to test them at abraham leading the to talk about how important are they really. And the touch in some ways being sort of a metaphor on there with you and for you. We have to work at out. We used to believe the touch the we had or the relations we had with people like bank tellers and travel agents and Financial Advisor is was very important and they have all gone away because of digital tools. I think the question in medicine will be what is the essence of that relationship . Where is it . It is so fundamentally important that it should go away. What can or should go away they can be replaced by digital tools. I think we can blow it by saying the relationship needs to look like 50 years ago that was magical land important because i think there are so many parts of it that our data gathering that can be done digitally, efficiently and better but i could easily see the we are going to take it too far and forget the we are not booking a restaurant reservation or plane reservation we are doing something fundamentally human and ethical and that will be the challenge for us for academic places and educators to get the balance right. Medical team, nurse practitioner, other people who will assist in developing a team that can help the physician. Thank you. Another set of questions. People ask the question how are we going to save money with these computers . That was part of their touted benefit. We have to save money with computers or with something because the Health Care System is bankrupting our country. We will not be able to afford our lives, teachers and cops if we dont get a hold of health care costs. Part of it will be allowing less expensive individuals to do things the right now we think doctors need to do. I want the doctor in a way of thinking about dr. patient relationship by want the doctor today to be the one gathering information to make a complex diagnosis. There is a lot i joy and a primary character primary care doctor does that may be better at it than we are and more expensive than we are, everything for patients and families can do if given capacity and schools to a nurse or nurse practitioner, health coach, and part of the workflow thing right where the productivity does come, we rethought the work and said what does a doctor in need to do . What can others do as effectively or more effectively lessexpensive the . How does it weave together into something that feels holistic for the patient . The advantage of the doctor doing everything it is all in one place. The disadvantage of disaggregating it is it is done by ten different people so unless that get pulled together somehow into something that works it makes life worth for a patient. That i think is the kind of thing we will ultimately figure out but we certainly havent yet. I think the mic is coming your direction. We have another one. I have been treated for Breast Cancer at stanford hospital recently and i have seen the best and the worst of what technology can do. My question is when the doctor is looking at the monitor when i am not being seen as a person and it happens, i am generally too freaked out to say i am over here. You are too freaked out and afterwards, i am like what can i do as outpatient . Doesnt have to be Breast Cancer. To i dont want to say corrected the doctor but what can i do to get them to see me in realtime as a person with certain needs . I dont know if this will reassure you or his you off but the doctor is as unhappy about this as you are. Is important for people to know. People sometimes finca doctors out there playing video games. They are not really good with patients anyway and this gives them something to do. This is something that the doctors are deeply unhappy about, that they are spending so much time and energy feeding the computer. What we hope for that the computer would give us this data and help us but we didnt think about how does the data get in there . Today the only way it gets in there is as you are talking to the doctor the doctor is doing all of this. The only Solutions People have come up with so far are people called scribes. You may have practices where they are usually young premedical students hired by the system to feed the computer so you go see the doctor and there will be a third person in the room . That is the scribe. It is a work around. I was talking to someone before at the Medical Clinic where they use google glass and the audio and video is going to someone in a remote place. Where i think this will go eventually, the bottom line is i think it is okay for you to remind the doctor and say can you look at me for a second, i am here. Most doctors will be responsive to that that there is this relentless drumbeat coming from the computer that cant go away right now unfortunately and so you need to think about where we get our care. Ultimately this gets solved by ergonomics and technology so ultimately, there are places already doing it where the computer is not in the side or behind the doctor but between the two of you, not between the two of you like that old board game battleship but on the side, you and i talk and there is Voice Recognition and the note appears in real time and we look at it and get it in real time, there are practices needing to do that and you concede that coming but turnout you are well within your rights to remind the doctors that you are there. It is important to have little sympathy for the doctor and recognize he or she isnt having a good time either. Hang on one second. A question right behind you. Can you tell us your opinion of how technology affects physicianss sense of responsibility for Patient Outcomes . That is a really good question. I think that it is hard to disentangle that question from the overall environment we find ourselves in because the technology is only one of two see changes in the nature of medicine today. The second is tremendous pressure on doctors and Health Care Systems to deliver better outcomes, more Patient Satisfaction fewer mistakes that in lowercost shorthand is value. In the old days there was no pressure on doctors or hospitals to deliver value. You went to stanford, we had these markes and u. S. News said we were great hospitals so you went and nobody knew if we were good or bad at what we did. That is changed in the last five to ten years and now they are publicly reported on the web and our pays influenced by the outcome and when i hear your question i am thinking it is not so much computers changing our thinking about your outcome, it is the we are now in an environment where we are being measured on your collectively outcome, it somehow the computers and enablers for that so it goes both ways. Were thinking about it more and we used to, we care about it ethically, i think about the same most doctors are good people who went into the business off because they want patients to do better but we previously had no financial or transparency incentive to Pay Attention to the outcome of the hundred diabetics in my practice. Now that is being publicly reported and the computer becomes a vehicle by which we are measured and so that is a long answer to i think we are paying attention to it but the computers by virtue of being the enablers are a distraction. We are thinking about your outcomes but the way that comes at us lets be sure we check these three boxes because of those will be the three things that get measured that end of influencing our payment which takes us away from thinking about you as a patient which is what we want to think and more about making sure we checked all the right boxes. We have to weave that together get the outcomes that we care about but also make sure we are remembering that it is a real person there. I dont know quite how to phrase this but i have had two bad experiences at stanford all of which had the same characteristics. A physicians assistant comes in very concerned and really listens to what the problem is, looks on the computer at the record, assimilates the information, the doctor walks in, doesnt listen to him or her, doesnt read the computer, doesnt read the summary sheet prepared on one piece of paper to summarize everything, looks at his watch this is three times over in the last year and says i really have to move on. I have gotten nothing and stanford has gone 750. I am sorry to hear that. You can hear stories like that everywhere. There are good doctors and that doctors, good systems and that systems. I spent plenty of time at stanford and there are many terrific people there but i do think that there have been surveys of physicians and this is probably the least happy time for physicians in our history. Let me add something. I was hospitalized twice at stanford and the doctor without reading anything on the computer or listening said what makes you think you can see him . I spent ten days in the hospital. Hard to describe what happened to you and i am sorry to hear all that but the pressure, this is not an excuse because you have a right to have a good doctor who cares about you and reads the charge, and it is enjoyable. I like my job very much in five or six years ago when i began to hear more doctors moaning about their jobs and wining and there was a part of me that says this is dinosaurs, they will get over it and it is quite real. This is a time where medicine is being wrenched from the old way of doing things to what will ultimately be a better place. I am quite convinced you could get very nostalgia about marcus will be at how well it was, but you dont want Marcus Wellby to the doctor anymore, the lack of data, the lack of incentives to deliver highquality state care at reasonable cost, care is better today than it was thin but so much of it is on the backs, nurses are in the same predicament, so much is on the backs of the clinician because the systems that they need to deliver that kind of care are beyond the capacity of individuals but the technology has not been good enough to catch up with the demand, but ultimately we are heading for a better place. I told the story of a few times, talking to medical students, a year ago i was trying to shake the mop and said you folks have entered a different feel than the one i ended 30 years ago because you are under your entire career relentless pressure that i did have relentless pressure to deliver the highest quality, safest, most satisfying carry the lowest cost. Kind of want to shake him up and one of the students raised his hand and said exactly were you trying to do . I thought that was the best question. For a doctor today, and nurses, we feel like why is our world changed . We went into medicine when Marcus Wellby a was on, why is this happening . It looked important to say it is happening for all the right reasons. We have to figure out how to deliver better care more satisfying care, cut the costs, the only way we are going to do it is to get to system that is more where the computers were cant happen to figure out how to get there yet. I dont feel people were having the right conversation. They were passed off but not talking about here is where we are, cant go back to paper, how do we make this better and until we Start Talking to each other in the right way to change the dynamics and policies i dont think we will get their. When we do i think we will and i think this will be a better professional that will deliver better care for patients. That is a great note for us to wind down on. Your book more than anything else will get the word out to what is not working and what could work. It is very insightful for me and i thought i knew something about this and you articulated so beautifully. Thank you for coming up here. Thank you all. [applause] thank you so much for coming. The books are for sale by the register. Abraham verghese as well, Robert Wachter will be signing into the lineup i will bring to the signing table. Thank you so much. [inaudible conversations] every weekend booktv offers programming focused on nonfiction authors and books. Keep watching for more here on cspan2 and watch any of our past programs online at booktv. Org. This is booktv on cspan2 and we want to know what is on your Summer Reading list . Send us your choices. tv is r. Twitter handle. You can post it on our face book page faithful. Com booktv and sending email to booktv cspan. Org. What is on your Summer Reading list . Booktv wants to know . On july 14th harpercollins is publishing the second novel from harvard b, author of tacoma mockingbird. The second book will be released 55 years after the pulitzer prizewinning first novel was published. Many bookstores are marking the occasion by offering special programming and operating hours. Here is a look at what some bookstores have scheduled. On monday july 16th and nationwide barnes and noble locations will be hosting public readings of to kill a mocking bird. In north carolina, raleigh books will screen the film adaptation of to kill a mocking bird and the following morning at 7 00 a. M
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