Members what kind of arguments can we bring to the table to help us convince our Public Officials that libraries matter in the community . This is a perfect one to end on because as i write in the first chapter of the book, wrote this book not for the library and the my love in the audience but for other people trying to make the case and specifically for people like you who are Board Members and for people who are in decisionmaking postures around making business whether its principles of high schools or town managers or whoever it may be too tried to decide on a budget. Thats exactly the point of this book and i hope it proves to be useful and you can actually borrow from your local public library. You can use an independent bookstore to buy it. Its the core of my argument that these are extraordinarily important institutions to democracies and i think this is extremely short money for the return you get. I dont have an economic model but i actually think it would be just made up great i think we all know the importance of these libraries to our kids, two are seniors and people seeking jobs the people trying to do creative and innovative things. I think in so many ways libraries serve a core function in our democracy. Right now we are expecting libraries to do things they have always done better physical and analog way and expecting these cool and innovative digital things. We are just giving libraries the same amount that we eyes half. The math doesnt add up. We still have to have collections and more research and development today. I think towns need to step up and individual citizens do and people like me need to write checks to her friends and libraries and institutions that make grants like the knight foundation, this is a moment where we need to put more resources into libraries to get over this transition and really to take advantage of what is in front of us. Bless you for being on our life life the library at board as a nonlibrarian and i wish you luck with that fathers and mothers who oversee the town to the free library of philadelphia. Thanks for the chance to be here. Have a great night. [applause] omagh had a reputation in omaha and the United States as a city that when you came in if you were black you needed to keep her head down and be aware that you are going to be served in restaurants and wouldnt deal to stay in hotels. When the club began their operation the idea and in fact the term civil rights, they use the word since social justice because civil rights wasnt part of it at that time. The idea of civil rights was so far removed from the idea of the creator of the community of omaha at the United States that they were operating in a vacuum. I always like to say they are operating they were not the support groups. They were not the prior experiences and of other groups to challenge Racial Discrimination and segregation. Union pacific is one of the premier road road companies of america. In the Pacific Railway act signed into law by Abraham Lincoln so combined several Railroad Companies to make Union Pacific and they were charged with building the Transcontinental Railroad that connect the east and west coast. They were moving west and Central Pacific started on the west coast and was moving east and they met up in utah. That is really what propels us. We become that point of one of the gateways to the west. Next book on how technology is changing health care at the bedside and whether billions of dollars in federal incentives for health care to go digital have been useful or destructive. Robert wachter is the author of the Digital Doctor hope, hype and harm at the dawn of medicines computer age. This is an hour. [inaudible conversations] hello everyone. How are you all today . Good evening a welcome. We are the nonprofit partner. We are pleased to welcome our speaker tonight dr. Robert wachter who will be in conversation about his new book, the Digital Doctor hope, hype and harm at the dawn of medicines computer age. His book is available for sale upfront and he will be signing after the reading tonight. He will be in conversation tonight with author educator and physician dr. Abraham some quick housekeeping items. Please silence your cell phones but feel free to take pictures to each leave Facebook Instagram whatever it is that you do to make your friends jealous that you were here tonight. Also for q a please raise your hand if i will come over with a microphone since cspan booktv is taping tonight. We want to make sure your question gets reported. Im going to briefly introduce abraham and he will then introduce robert. Abraham is an internationally popular author and a prominent voice in medicine with a uniquely humanistic view of the future of health care. His memoirs and novels have sold millions of copies then translated into many languages and topped bestseller lists while his New York Times articles making the case for greater physician focus on the patient and an air of Technology Advances in medicine have made waves in the medical community. His novel cutting the first stone was a runaway hits 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. Please help me give a warm welcome to dr. There are geese and wachter. [applause] thank you so much that cold for that wonderful introduction. Can you all hear me pretty well . Is such a treat for me to be here with my good friend bob wachter the last time i was here was who someone bob is close to notice his wife a book on mother, daughter and me mean its a treat to be back with bob wachter. I have actually known bob for many years and we cross paths without knowing it. When you were at the Robert Wood Johnson fellow at stanford you are asked to be in charge of the first aids conference and i have a very distinct memory of it. There was a poignant time as you remember sitting and watching it sit in at the hyatt in seeing randy shultz off to the side looking at this. His book is a book that got me so committed to the hiv story. Bob trained at the university of pennsylvania and his residency at the university of california san francisco. He is a Robert Wood Johnson fellow as i mentioned and has gone on to a distinguished career in the field that he invented so to speak on a very important article. He coined the term hospitalist and he is truly the leader of the Hospitalist Movement in america. Its interesting bob i think any times people have hated us against each other. I am the luddites which i dont think i am but certainly writes about the dangers of technology and ive always viewed you as someone who very much embraced more than i did so this book was a bit of a surprise. I loved it and a tack on technology that completely took me by surprise. I would like to begin by asking what the motivation was to get you to this point . First of all thank you abraham for doing this and we go way back and i dont know if you recall that i reviewed that journal. Luckily i loved it so that helped her friendship along the way. Abraham is my role model as an author so thank you. Those of us practicing medicine and teaching have been waiting for years and computers and our world and the rest of our lives because of their iphones and they were so magical so transformative that it was quite logical to me that computers in medicine would make everything better. Particularly for someone like me my main academic interest has been patient safety. I cant tell you the number of mistakes analyzed in csf where we sat there and said we just had computers. Someone misread the doctors handwriting, likeminded indecipherable or didnt realize the patient was allergic to a medicine on a computer database. I think the combination of the wonders of computers in the rest of our lives and the desire for computers to fix the problems we have had led us to anticipate this moment for many years. Medicine did not go on its own. It required 30 billion of federal incentives but then assure period of time it really went and logged digital very quickly. Almost like a tsunami of digitization of the Health Care System that happen assure period of time and i was shocked by how badly things were going. Those of you who are physicians or nurses know this data change the work in ways that often there were positives to it but often made harder and less efficient. It screwed up the work was of all of us who have had the experience of going to see your doctor and you ask a the question in the doctor does that and ask another question and the doctor does that. In fact you turn the bird i patient. So at the end wondering why was it so bad and the beginning and my wife katie right through next hands and she began writing stories about technology and medicine and they were interesting. One day it ucf david hit a 39 overdose of a common antibiotic. It does was supposed to be one pill and we gave him 39 pills. Luckily he didnt die but as i listened to the stories during the meeting and it was a simple airport alerts were ignored ignored pretty mil basin technician would have seen an order for 39 pills and said whats this about and tap someone on the shoulder but that person has been replaced by a robot. A young nurse said this is really weird but i know to get to me it must have gone through computer and a person and i have my bar code. She bar codes it in the computer and she gives the kid 39 pills the equivalent of seeing a sign that i am a highway someone going 5 miles an hour. I came home that day and i said to my wife can you write about this and katie said you must do this journalistically. I said what does that mean . He said he will have to get out and talk to people. I said i hate people and she said i know that. [laughter] the only way you will get this right is basically going around the country and talking to vendors and policymakers and doctors and patients. That is how i spent the last year. By the way he is kidding when he says he hates people. I mostly like them. Theres a section in the very end which even though that mistake the metal mistake is when he talked about as you embark on this book i was pleasantly surprised to find you didnt begin the book with that. He began with a completely different idea. Would you mind sharing that with us . I thought that book might be the story might be the core of the book and i therefore wanted to in some ways be the anchor of the book. The story that i start the booklet is the story of faith position surgeon at the mayo clinic who i happen to happenstance ran into when i was a professor there. Some colleague said to me theres a surgeon here who switched gears from being a surgeon to being a computer expert and i said thats interesting. My colleague said why did you do that and she said one night when he was on call his errand turned at medical school, there were four patients who had code blue meeting their hearts stop within an hour. That might not strike you as weird if you watch tv where that happens in the every hour in the er but i can tell you in 30 years of clinical practice i have never seen that. There were 30 code blues so it happened to him. Three of the four patients died and as he came to think about this he recognized 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 and health care. As i was interviewing him and hes telling me the stories of big macho guy, muscular guy he is telling me the story and he stops and starts crying. I said this is so profound. The experience he went through and then at the end i said you must be thrilled now we finally are computerizing health care because the government got involved and put stimulus money behind it. This must be a great ruling for you and he said they are selling it as snake oil. I said its interesting to hear someone who has devoted his life to computer medicine is tremendously disappointed. I wanted to point out the tensions between we are not insiders, between these two worlds of clinical medicine and those who see and take care of patients doctors and pharmacists and the people who designed a computer system. I cant believe part of the problem is those worlds are not working together and operating the same silos. Matt burden is the surgeon who became an icon for this effort to try to bridge the field. That was part of it and part of it i wanted to demonstrate to people i hope that even though this is a book being written by a doctor about technical field and how this is so still defying leap warring. I thought this story was not boring. Theres actually huge amount of drama and part of its funny and it really has some life to it are the characters were really adjusting. So that was why started that way and i felt like it was the right way to get into the story and raise some of the key points of contention in the story. Seeing as theres a section and if you wouldnt mind reading that horace. While bob is finding the page i want to say what it pleasure just to see so many of you turn outside i want to especially thank cap players. I have a special relationship with keplers. I came there for my own country in 1994 and i never thought id be living in the neighborhood and being able to basically cycle over and walk over so thank you so much for being the host for this. All the folks who work here are like family and they are often recommending books to me. Thank you all for coming. Its delightful to have you all here. This is part of the other issue. I wanted to frame my own point of view and my worry was people was see part of the reisner brode worth the books i saw about computers and health care were either highly technical or relentlessly hype painting a picture of this Wonderful World that maybe we will get to eventually but not feel like youre affected my daytoday reality. And yet i had a feeling that someone would read the subtitle say hope, hype and harm at the dawn of medicines computer age and say this is a luddite screen. There were people who would say that the pullout the wires and bring back a threering binders. We can do this digital thing lets go back to paper and pencil. I think they are crazy. We have have to make Health Care Digital periods Health Care Digital. Its only lead Health Care Digital periods only way to write that we have have not gotten a price i wanted to frame my own point of view here. The last paragraph i will tell you why i wrote that. While this is a book about the challenges we are racing at the dawn of health cares is digital age if you are looking were dr. Luddite you have come to the wrong place. Part of the reason we are experiencing so much disappointment is that in the rest of our lives Information Technology is so astonishing. Ive no doubt even a medicine are bungling adolescence will ensure productive adulthood. We just have to make it through this stage without too much carnage. Of course if he picked up his book looking orb reckless hyperbole you wont find that here either. Where late to the digital carnival but there are markers everywhere telling us to transform everything and the answer to all of Health Care Sales is being developed even as we speak by his soontobe billionaires 20something tinkering in a garage. Some of it may be real but for now despite some scattered rays of hope the Digital Transformation of medicine remains more promise than reality. Like a bike shorts that take her pulse counter steps in reader moves are pretty nifty but they arent the change we need. Making this work matters. Talk of interoperability federal incentives bar coding and machine running can make it seem as if health care Information Technology is about well the technology. Of course it is. But from here on out its also about the way your baby is delivered, the way your cancer is treated, the way you were diagnosed with lupus are reassured you werent having a heart attack the way when it comes down to whether you will live or die you decide until the medical system that you do or you dont want to be resuscitated. Its also about the way your insurance rates are calculated in the way you figure out whether youre a 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 through a remarkable and somewhat disquieting degree by how well the technology works. That last paragraph did not appear in the print and make even the first version that you were nice enough to look at. Our daughter read the preface and she said this is really good and its good writing but the book doesnt have anything to do with people and it needs to. You need to tell folks why this matters and that is where the paragraph came from. Im very glad for her, she graduates from college in a week week. One of the things that strikes me as we have been very Fortunate One of the things that strikes me is we have been privileged to watch this transition and for many of our younger colleagues who are at the reception earlier today it has always been computerized in a sense. I was charmed by the book when he talked about the shoebox routine where you went through the shoebox looking for lab results. Talk a little bit about that. I see some physicians in the audience. One of the fun parts of the book is people coming up to me and saying oh yeah i forgot about that and the young folks have no idea what that is. In this case it was the russian russian recollection of my time at the va hospital in the way we got our Laboratory Results was known as checking the shoebox. The shoebox that on the card table outside of the Clinical Laboratory and all of that lab tests the blood counts and all that were filed roughly in alphabetical order although not perfectly in a shoebox outside laboratory. Every day that was part of the ritual. We would go down and look through the shoebox duties flimsy carbon copies. Young people dont know what a carbon copy is that as we used to have a new felt it was a little tiny miracle if you found all of your patients lead test results. So when you grew up with that how could you not be so excited about the idea that all the Laboratory Results were going to be in the computer and theyre all going to be trended in all sorts of wonderful things. I think thats partly why its been so disappointing. The lutheran era in which we knew this needed to go i. T. The new technology could help us with fundamental things and thats partly why we have been waiting for it and why its so disappointing so far. Ewiner defendant arrow where we use radiology and find xrays and go to the folder. I would never want to relive those days so lovely to be anywhere with damage. If you could talk about the unexpected consequences that were not socializing with the radiologist and getting the benefit of that traffic. I was one of the things i had that computers theres a tendency to believe that computers just digitized to make it better and sleeker and analyze so you dont have to dig through your shoebox and thats all good. Those of you work in technology and other fields have figured this out out but this is all new to us is that they change everything about the dynamics and the social relationships and the story i tell was the one that just came to mind when i began thinking about this was 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 one room where the radiologist read your chest xrays. The reason i say that is because every day, every single team came through that chest reading like a carwash one after the other. The radiologist seated in front of the war that had the xrays hanging on them and ask you what team theyre on and push a button and the thing would goround like the dry cleaner turning on its side. For young people ive had this thing called the films. This film there was only one copy of the film and we had the radiologists report at there were something magic in that interaction. Radiologists radiologist they tell me the story and you would say its a 60yearold woman with lupus who comes in the shortness of breath in the radiologist would say thats the story and this looks like tuberculosis. Thats not that the formal reading on paper was but it was from his interaction they learned from each other. 15 years ago radiology went digital and therefore the rest of medicine because now when we had filmed was the date chest xray. It was now a c. A. T. Scan or an mri with 100. So the cost of digital storage plummeted and about the year 2000 radiology went digital. Thats all fine and as you say its better. I can see that home and you consume in and look at different views and thats all wonderful but the minute that happened those ended. Nobody predicted they would and then nobody wanted them to and that they ended unambiguously everywhere. The reason they ended was we no longer have to go to reality. There was no more film. It was ubiquitous so we stopped doing it. So that magical interaction between the clinicians in the radiologist went away. I think to the detriment of both. Radiologists. You would think if youre a radiologist and your son goes into the field you would be proud and your son was one of the innovators in the field and responsible for radiology going digital, you would think his father would be incredibly proud but a nickname for his son is the man who ruined radiology. The radiologists are actually quite unhappy about this because they are like maytag repair man sitting there with image after image in a sterile environment and their lonely and actually feeling like theyre not connected anymore. Then all sorts of other stuff happens when the geography changes. If i dont have to go to the Radiology Department why do i care fits in if its in my building . Well then you have tele radiology and you begin to say the average u. S. Radiologist makes 400,000 per year and makes about 40,000 a year. That is the question when you are talking about the Radiology Department. They do very well. Questions abound power relationships, geographythosthin all of those things reallyn waabou offsets what computerization was about but is precisely what is happening and is go b very, very field quakes another thing we have talked about from i would never want toi go back to the days ou of trying to hunt the old sharks. Someone check them on their office. It was a it was a nightmare. It seems marvelous. E yet as you and i discoveredmarv the computer meledical record me is very different andch more ways than just the data is recorded. What struck me the former editor of the german medicine review. In the rehab hospital he washe m struck the fact that medical record which i guess he managed to see had major dialogue and discussion nothing about him. Clicks him. Clicks in many ways the medical record has like your writing is morphed from nonfiction to fiction. Now i just checking boxes not really thinking much andittlab he foundou in the medicalrom no record anf lot of stuff thatbos, never happened because it isrecord t copy andhe paste it. Becae it and the. You have made isu made s before paying more attentionion t to the record that to him as being. Part of the story this was one of the heroes of american medicine duringgland the era that hiv emerged and hea figured figured out how toto treat and prevent. You would think you pull up a a chair and check this guypened bec it never it never happenedo because everyone seemed so concerned that thenum relationships with the and the record has become this Christmas Tree on which weto de. Are hanging. Part hanging. Christ part of what i came to light was to my recount theappyit history of the record. It ise or rec easy to be unhappy with the vendors, why theppy createddocts the system. The vendors arester just making something happen that had to happen. The real problem is the doctors note now has to serve so many pati masters. En yes, the patients story 12l that is a minor is a minor character. Have to send the bill will prevent from being sued, someone who figures it out. She has become a e of calamity of checking boxes and copye and pasting things the stories i heard was in intensive care dr. Told me a story of taking care of the very sick patient in the icu. The record had 20 or 25 pages of gibberish i copied and pasted notes, copy and paste the above results, xrays filled with data. But he wanted to know was what the story was. He said, let me take yesterdays notes. His onlywant t solution that heo could come up with was printing outjust a todays notes, 20 pages, printed out yesterdays notest toy , held them up againstes pages each other to see if he could identify what appeared to be a. Conan them to try to make any sense of is going on. Bi that is not the way it usedntion to to be. You actually had to distill it down but it felt like we are the pay moremet attention to the person. Clicks something more. I i just published a piece in the american journal. Nd we asked physicians to tella us about instances they knew where someone had missed something the lead to a consequence. Ss o we collected about 200 suchwe col anecdotes. Leuc the chart the chart never captures that because the child becomes a fiction. Ort of you get all these things. I actually think it is taken as sinister turn. T seem less concerned about truth. Clicks i worry about that. Medicare came down a couple years ago. Waha if you remember the pictures the bloated bellies what you dont see th the United States. E the epidemic emerged because of the consultant coming in and saying all these patients who appear to becamen malnourished if we kick off an algorithm that saidis malnourished and low protein level, lets call that this because medicare will pay us an extra 50 a pop. This epidemic and they Start Talking to each other. No, i dont think so. The hospitals both said sorry, it sorry it was a computer error to the way it was. There is that is only a piece of what i think is going on plantations are beginning to notice it. About 5 million pages tothe sp patients can now read their ic doctors notes which is an are exciting development. Marginalized both in ceylon a right a copy of my record andsay i wa thats are your yntou get itl in a month. This is digital and all yous a heal need is a password. This isn usit a a a healthy trend. Not overly bothered are scared. Not over they have to clean up ourittlli language att little bit. The patient is sop for shortness of breath wetnesof breath, we have to be [ careful about thatug. Ginnin [laughter]it in addition, it says here that the dr. Listens to my lungs and heart and i dontare recall the dr. Taking Us Government stethoscope out of his or her pocket. Yes, it is but it is this sort of relentless system that documents a bunch ofofha factoids disassociated from has the purpose of the youror trying to do. Ause that is part of why its sore tin important. Appropriatelypurp ethical terms. Es what is i purposes. We get distracted get distracted from that y clicks i remember you hearing you talk in san t antonio and use the airlineeen so analogy. You have you have been associated with the field of medical mistakes for some time. I was impressed with another medical analogy about thethe Southwest Airlines flightthat dispatcher. Talk about dispatcher. Talk about that clicks a researcher who i interviewed at Brandeis University studies of the golf that professional coordination. The degree to which complex organizations make sense of really complicated fastmoving situations and for her phd thesis shee sense studied a number of airlinesovg and the way they did plain turnarounds, what happens if. Get severe and you have to turn around to take offoff again. It again. S anxt that turns out to be an extraordinary complex ballet the numbers of pieces. Wit in her bias when she came he in the airlines that did it in a systematic, computerized really a systematic, computerized way probably had it right. If somebody sitting miles s away at the air traffic airl control center for this awa process it was looking at alog bunch of checklists and said okay, for flight 286 they have the foot off the gas is on, its good. Southwest airlines which was due at the time there was a. Guy on the ground with the walkie talkie talking people yelling at people and saidng at op she was having one personicient with templates simultaneously and yet there was no question in her mind he worked better and was more efficient. She said there is something so about the relationshipeople d between the people andiguring somebody managing it will bring it together figuring out what is going on someone not doing their job, talking to them certainly that you simply cannot do you are doing it digitally at a distance and that is part of what we are seeing. Peters have driven us. Look at howth work is now talk todicine i each other through facebook. Ed it has given all of us andhavead to our silos and bunkersake where we hang out by ourselves with members of our own tribe. So much of like medicine is like that for someone has to talk to each other and make sense of complex situations command computers are made at horse clicks i want to make sure we have time for the audience to give us questions. I was taken with a hopeful note that you strike. Was very imagine strike. Imagine that it will alwayss be this way. Fe or i i thank you for that. Wa share with us that lasts here section of the book where you have some of the utopian, a vision of what a hospital might be like. s very, we have scaffolding allent portal for them to do a lot of work. I said, i think we can see how we get there. The question of getting there to me, hinges not on the technology but on the choices we make choices we make, social relationships, the political decisions. But i cant plan is that islitical not unusual money flows. What i came to learn is thats not unusual. There is a concept in the it literature known as the productivity paradox. If everybody had this experience. You bring the computers and you think in two years it will be better and faster. Years later nothing has happened or its gotten worst worse. Then in year five or ten it starts Getting Better and its not because the technology has gotten better but because people have reimagined the work and built it around the digital infrastructure. We might say were so late in the game that widen we reigine the work b save some time. No one ise woing smart enough to do that. Yougli cannot figure this out until youre working with tools woul struggling. Henry fordd is. Once reputed to have set up as people if they really needed they would have said faster horses. No one no one has the and to have theun ability toin ts understand until they are inmuch the world. As half. I dont think its in twoars but i years or five years. Years. Ink it is a ten or 15 years trial clicks the stone age does not end because we ran kind out of stones. [laughter] quick stats right click to register that yesterday clicks i like that. I like that. The title of your book. Would [laughter]his sect clicks this portion. Ioend of so this is actually i hate to i hate to give away the ending but i wanted to meander from clinical medicine the policy to thepati goal ofts patients in the Silicon Valley chapter. Wo a broad swath. Broad swath wanted to bring it back to the patient. I i felt like i needed to bring it back. That is why the sending. A couple of years ago i was caring for patients ae patient in the 70s in a intensive care unit aient challenging case. Clinically obvious the patient had widely metastatic cancer and die several members of the family had not come to termsrea with this reality. On top that licensed significant conflict. The patients son and daughter cool toward each other in the seven daughters husband eacot could hardly stand several. Coulne as mr. Gorton and drifted inof con and outio of consciousness as that with the family. This my longstandinghem resentment. I describe thed be clinical situation, told fu them how it was sured mr. Gordon was dying gave my assessment that ongoingthon treatment be futile and inhumane recounting my assessment all of them missed my Partner Summit approach, told him i understood their desire to temp keep mr. Gordon youve theorest. T time had come to stop trying. The family members began to describe thea memories of w their times and recall his attitudes about endoflife care and became clear he would not have wanted aggressive care at this stage. I could feel the family members casting aside their is either grievances of the coalesced around his interests. Questions answered my leftait the room and returned to thed it w icu. As a few minutes later he toldng ts me the family had decided it was time to allow stand to die peacefully. I repliei d i understood how r wrenching his decision wasthnu but it was the right one. Back to the waiting room to join his family. O t i entered the room andpt f t inform others switching from our current fullcourt press to comfort care and asked him to turn down the oxygen on the mechanical ventilator, all the entities except for one more thing and bring chairs in the roomand toll to allow the family to be at wait the bedside duringin his finalk minutes. To s h watch out to the waitingt room of the time had come. They entered the room one by one. They nodded at each other and took seats surrounding the patients. Hs. Ey still now unconscious as he morphine drip. E drip the stag. E was the stage was set but i noticed a problem. Beid in his haste to discontinue the various treatments the nurse had forgotten to disconnect the bedside cardiac monitor which continued to flickr a fewth feet above mr. Gordon said. St one of p his profound momentsy an nearly impossible andcy, mystery all the familys eyes were raised, not searching for truth truth god but watching squiggles into the electronic signature of a harp march across a rectangular screen. His son was sitting closest to the monitor. The i put my hand on his shoulder. Speaking to all of them i said your debt ish comfortable and ims glad youid y could beda here with him. L be but and i pointed to aon t s heart monitor, there is is nothing on the screen thee of matters. And that person if. The as the screen with the black the familyn members shared a look a look of shock of the clarity and acceptance granted transcendence maybe even love. For. For a moment of gathering himself each turned squeezed his hand and stroked his arm twist his touched his cheek. The scene was pure, in a wayso that isme hard to describe quite beautiful anesd then he no died. Well. W clicks thank you. Clicks you. Clicks we have time for questions. Clicks thank you for that review of your book. Pectof one of the most important aspects of patient physicianyove relationships is trust. You have shown how computers intervene and dissociateoat trust by making the handson interpersonal communication no longer than major factor in the examination. Ou can you talk about your y vision of whatur the routine will be in the future thed trust, handson, questioning, interpersonal relationship back in the medicine like such a a profound and importantd question. Hi n none of us know for surefr because we have talked about this many times there times, there are aspects of the handson portion of the relationship that are probably too inefficient to survive. By that, i mean, the 20 minutes or 20 minutes or so that it may take together the history or are they really are way of saying ineed to fi care about yound on there with you and for you. Tellers financial buyers are and f important. And what parts of the relationships can ensure go away because they can bean bre replaced by tools we are going to take it too far and forget that we are not booking a restaurant reservation a restaurant reservation but are doingl. Something fundamentally human and ethical and that for would be the challenge fort bala us academically, educatorsnc academically, educators and figure out how to get the balance right. [inaudible question] clicks other people who will assist in developing a a team that can help the physician clicks thank you. That brings you. That brings up another set of questions. People asked the question how are we able to save money which was part of theysic touted benefit, and we haveques to save money with somethings onof because the healthcare benefi system is bankrupting our country and we will not be able to afford our lives teachers, cops do not get a hold of healthcare cost andd co i part of it will be allowing pa less expensive individuals oexpeive to do things the right now we think doctors need to do. I want the doctor, a a way w of thinking about a doctorpatient relationshipone ga the dr. To be the oned gathering the information to make a complex diagnosis. There is an awful lot that i do that probably can be done by other people that may bea better at it and arele tha certainly less expensivertaiy everything from patients andeveryt families. Ng mi that is part is that lead to something holistic for the patient. W oe the advantage is it is allls holti in one placec. Or the disadvantage is it is being done by ten differentli people. Luis gets pulledhat together it makes life worth h makes life worse for a patient. Hang on one question. Clicks hello. I have been treated for Breast Cancer and missing the best and worst of what technology can do. When do. The dr. Is looking at thee d monitor, when i am not beingappe, seen as a person and generally to freak out to say im over here. And then it is like afterwards im like, g what like, judy what can i do as a patient to not correct to dr. Get them to see me in real time as a person with jus needs clicks i i dont knowle to if this will reassure or puts you off. People think the doctors or other playing video games are not get the patients anyway. This this is something thatvidega doctors are deeply unhappyts anywa about, they are spending so doct much of torheir time andso energy. But we hope for is a computer will give us this data can we dont thinkbut about how that data gets in there. As as you talk to the dr. Is doing all thisis. You always come up come up with called scribes. Practices, usually young to premedical students. You go to the dr. Is ascribed. It is work around. I was talking to someone who works. Essentially scribing. Where this will go eventually, the bottom line is i do i do think it is t okay to remind the dr. Andu lo a say can you look at me for act second, im here. Onsive t most doctorso are beingere responsive to that. There is this relentless drumbeat. Th you neede to think abo ultimately this get solvedpefuy th by ergonomics and go technology. Ultimately places already doing it they can. Between dr. Between doctorke theld between the two of you,old boardgame, on the side. You and i talk and there isd t Voice Recognition andit aea another appears in real time and we both look at me in realtime. You can see that coming. For now youre well within your rights remind the dr. You are there. Is important to have sympathy for the dr. Andr recognize that he or she isthe not have the time i clicks hang on one second. A question right behind you. T clicks you. Ts clicks tell us your opinion ph about technology affects physicians sense physicianse o sense of responsibility for Patient Outcomes clicks thattio is a good question. I think i think that it is hard to disentangle the question from the overall environment we finindgle ourselves in because thehnolis technology is only one of two changes the nature of medicine. The second is tremendous pressure onems doctors and healthcaretter systems to deliver better s outcomes more Patient Satisfaction fewer mistakes and lower cost clicks shorthand, we talk about value. Pressure on doctors or hospitals to deliver value. We have these marquees and are great hospitals. You went and no one knew wherew ife you put your bad. That has all changed. Now our data is publicly recorded on the web andar payment is influenced by outcomes. And i hear your question i am thinking it is not so much that computers are changing that we are now inments an environment we are beingh measured your collective th outcome. The computer in some ways ases bo an enabler. It goes both ways. We are thinking about it more than we used to my care about it ethically about the same. Most doctors are good people. His had no financial or transparencyntioto incentive to pay attentiont to the outcome of the 100 diabetics. Nd now that is being recordedby wch w publicly recorded and thesure computer becomes a vehicle by which they are measured. Thats that is a long answer the computers have become a distraction. You think about outcomes. E three lets be sure we checked these boxes. The three the three things that could measured within take us away from thinking about you as a patient and more about making sure you check the right boxes clicks b thatfluee together the outcomes that israel person. As we clicks i dont know quite how to phrase this. Ltoget i havehe three bad experiences a physician assistant comesl which inha concerned and listens to the problem, looks on the computer of the record, as whites information the dr. Walks in, does not listen to him or her coat ist lien not does not read the computer, does not read the summary sheet to try to summarize, looks at his watch three times over andike says i really have to move sayi on andre i have gotten nothingdoct cliorcks am sorry to hear that. You hear stories like that everywhere. Good and