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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. Friends, it's time for another very special episode of A Health Podicy, an episode where instead of interviewing the author of a recent health affairs paper, we talk to a guest from the broader universe of health and health policy, someone helping shape the day to day discourse about our health care system and its future. Well, I couldn't be more excited about our guest for today, Doctor. Robert M.
Rob Lott:Wachter. In addition to his role as professor and chair of the Department of Medicine at the University of California San Francisco, doctor Wachter has done and accomplished a lot. Back in the nineties, he made his mark by helping coin the term hospitalist to describe what was for a time the fastest growing specialty in American medicine. He has been a trusted and influential voice on topics of national importance ranging from patient safety to digital medicine to our national COVID response. And today, he has a new book all about artificial intelligence.
Rob Lott:It just hit the shelves at bookstores everywhere, and it's called a giant leap, how AI is transforming health care and what that means for our future. I cannot wait to hear all about it on this latest episode of our Humble Podcast. Doctor. Robert Wachter, welcome to a health podocy.
Robert Wachter:Thank you, Rob. It's just a joy to be here. I admire what you do and the journal is fantastic.
Rob Lott:Great. Well, let's just, dig right in. And I think maybe before we talk about the book, I thought we'd start a little bit with your own personal experience with AI. Do you use AI today as a practicing physician, as a teacher, a researcher? What is its role in your life today?
Robert Wachter:Constantly. I was just on the wards at UCSF last week. And in the old days, like a year or two ago, I'm a generalist. And a couple of times in the morning, I would get a curbside consult, which means I would run into my favorite ID doctor and say, you know, can I take you aside? I have this case, it's tricky.
Robert Wachter:Didn't need a full on consult. I didn't need to see the patient. I just needed advice. Now rather than getting two or three of them, probably get about ten or twelve in the morning, but I don't get them from a human. I get them from usually from open evidence, sometimes from Gemini or GPT.
Robert Wachter:And the answers are pretty darn good. They're not perfect. I'm glad I'm there to look over its shoulder, but it's better than anything I've had before. It's better than what I used to get from electronic textbooks. It's better than what I certainly got from Google.
Robert Wachter:So I use that all the time. I'm using an AI Scribe, so when I see a patient now I can actually look the patient in the eye and listen to them rather than looking down at my keyboard. I'm using a chart summarization tool. Here's an interesting factoid. One out of five patients' charts are longer than Moby Dick.
Robert Wachter:Oh my. More than 600 pages. So the idea that I'm gonna be able to read that in three minutes before I see a patient is of course ludicrous. So those are the kinds of tools I use in my life as a doctor, in my life as an administrator and leader. I use them sometimes to draft memos.
Robert Wachter:I use Claude to help edit documents I'm writing. I think it's a terrific writer and editor. So it's become nearly ubiquitous in my life.
Rob Lott:Okay. Well, let's talk about the subject of your book. You call it a giant leap. That's a pretty optimistic title. You didn't use the title grave reservations, for example.
Rob Lott:Was that hopefulness that you, are espousing about, artificial intelligence something that you had in mind when you set out on this book project, or was it something that surfaced during the course of your research and writing?
Robert Wachter:Yeah. The latter. I think it evolved organically. I I am fully capable of writing a grumpy book because I wrote one ten years ago. It's called The Digital Doctor and it really was about electronic health records.
Robert Wachter:It was about healthcare going from paper to digital. And I wrote it out of frustration. I wrote it because all my colleagues were moaning about the electronic health record and how it ruined their life and this term pajama time. I came home at night and had two hours of work to do and I'm not looking my patients in the eye anymore because I'm so busy checking boxes on the screen. All that stuff, none of which anyone anticipated.
Robert Wachter:Then patients got their patient portal and now they could click a little button saying, send a message to your doctor. And so they did. There's a chapter at the end of the Digital Doctor, I think it's 27. People just came up to me and said, who was your ghostwriter for that one? Because after 26 chapters of grumpiness, there's this hopeful, I think this is gonna work out chapter.
Robert Wachter:And it's like, no, I can actually see how this gets us to a much better place, but not yet because we didn't really think about how to implement these tools in ways that would make things better. And I think in retrospect, we didn't have the tools that we needed, that the EHR succeeded in digitizing our information, solved a lot of problems, including doctors' handwriting, but didn't really do anything to provide us help in dealing with all the bureaucratic stuff we have to do, the prior auth writing, any help in decision support. And I guess the thing on top of that was my optimism is partly borne by these tools are remarkable and can do things we never could do before, like read a note, like deal with unstructured data. I can go to my tool, my AI and say, I've got an 84 year old patient who's got CLL who comes in with a fever, shortness of breath, chest pain, has a hematocrit of two, and a creatinine of 3.7. What do you think is going on?
Robert Wachter:You know, impossible. Any prior tool would have sputtered on that. So the tools are amazing. But I think the other part of the optimism, and this is sort of perverse optimism, is three years ago before GPT came out, it wasn't like I was sitting there saying, Google's terrible. I can easily imagine something better than Google.
Robert Wachter:Google was great. Couldn't imagine anything better until I used ChatGPT the first time. And I said, oh yeah, this is better. Do you know anybody who says the healthcare system is fantastic? I don't.
Robert Wachter:I don't know any doctor, nurse, administrator, or patient who says the system's great. So it really is a combination of these tools being remarkably good and the system desperately needs them, needs to have the kind of transformation that I think AI promises that I think is impossible without it. So my optimism came from both those things and really emerged organically from, I did 110 interviews. The more I learned, the more I thought about it. It's not like I'm naive, not like I don't think there will be unanticipated consequences or in some ways negative consequences, but I think the net chance for a positive outcome is much, much higher than the things I worry about.
Rob Lott:Okay. You talk about that grumpiness and then the shift to the optimism at the end of The Digital Doctor. I'm wondering if you aspire to sort of reconcile those two attitudes with this. You sort of look back on the ways you were, as you say, potentially naive about, the shift to electronic health records. Here, you're sort of walking the tightrope, if you will.
Rob Lott:How do you recommend other folks in this space kind of reconcile those two attitudes?
Robert Wachter:Well, I'd say the first thing is to admit that we can't possibly deliver what our society and our patients need without digital help. And that this is the form of digital help that we needed. We needed tools that can do the kinds of things that AI can do. I think also it's not like we in the world of healthcare have been static for ten years. So now that we're trying to implement this new technology, so ten years ago, fifteen years ago, we implemented this other technology called electronic health records.
Robert Wachter:None of us really had the infrastructure to do that thoughtfully. Didn't really understand how to think about return on investment for digitization, how to weigh privacy concerns against the value of having data and data fluidity. I think we could easily get snookered by a company pitching us something. If it looked pretty on the PowerPoint slides, we'd say, great. Think now as we implement these tools, first of all, the company is building them, I think are more thoughtful.
Robert Wachter:They are more likely to have clinicians engaged in the process of building them and understand that if it doesn't work in the real world, it's not gonna work and we're not gonna buy it and use it. I think internal to healthcare systems, we've got better processes and sort of more thoughtful and less fewer naive people who are gonna look and scrutinize. Like, what's the evidence this thing really works and do the kind of appropriate tire kicking. The tools are better and they're just easier to use. AI is not new in healthcare.
Robert Wachter:We tried it forty years ago, but we started with the hardest problem. We started with diagnosis. And that violates change management law one through 57. You wanna start with the easiest problem, the lowest hanging fruit, the ones that are gonna gain you buy in. Then once you have buy in, then you say, all right, let's move to more ambitious use cases.
Robert Wachter:So rather than starting with diagnosis, what did we start with with the new AI? We started with AI scribes. We started with an absolutely clear pain point that everybody complained about, doctors and patients. And we kind of fixed it with tools that really do this thing really pretty remarkably well, that aren't that terribly expensive. And they're not perfect, but they're pretty damn good.
Robert Wachter:But even if they kind of screw something up and they miss a word, it's probably not fatal. And I can tell you that every doc at UCSF, three or 4,000 docs now has access to an AI Scribe. Most use it, most love it. And at this point, if we turned it off, they would all threaten to quit. And there's never been a technology like that.
Robert Wachter:Usually it's like, if you turn it on, I'll threaten to quit. And so I think it has gained buy in and a level of receptivity for, all right, let's try chart summarization. Let's try having a draft, my discharge summary. All right, let's carefully try computerized decision support where the stakes are higher and if we get it wrong, somebody can be hurt. And let's figure out which company do we wanna go with.
Robert Wachter:Do we wanna go with our EHR vendor, which is building all these tools? Do we wanna go with a startup, which has maybe some advantages of nimbleness, but maybe won't be in business in three years? So all those sort of things, I think we're all more thoughtful, more mature about this than we were. And part of that was the learning curve of what we learned from the early experience and I think the painful experience with our first stage of digitization, which was really the EHR. Great.
Rob Lott:In the book, you write that humans are, quote, awful at anticipating the consequences of new technology. Obviously, that's a lesson learned from the move to EHRs. And I'm wondering, you do a good job in the book of describing how even though this feels like a very sudden innovation, it's sort of been in the works for the last five decades. But even if we look back to just the last couple years of this so called giant leap, I'm wondering if there are ways that you've been surprised. Is there anything that's happened in just the last few years, even since you've started writing this book, that you didn't foresee?
Robert Wachter:Yeah. I I mean, I I mean, the biggest surprise was the first time I used ChatGPT. It's like, my god. And I think most of us had that that holy cow experience where, you know, this thing can be kind of remarkably human, and that's both wonderful and part of what makes this so exciting and scary because it does increase the probability that you will over trust it. I'd never heard of this term hallucination until two or three years ago, where it not only can give you an incorrect answer, but it sort of bathes it in this blanket of BS so that it just feels credit seems like it's right because it feels like it's a human talking to you.
Robert Wachter:I've been surprised by that. Guess I've been But then also surprised by how quickly they've gotten better. And that's part of the challenge here. If you used AI two and a half years ago, you might have said this thing's not ready for prime time in a high stakes business like taking care of sick people. And you might have been right at the time, but a year later you probably were wrong.
Robert Wachter:And we've not really seen in healthcare a technology that has evolved that quickly. And that's part of the regulatory challenge. When the FDA says this pacemaker is good to go or this medication is safe and effective, they're dealing with something that's gonna be static. It's gonna be the same as it is today, three years from now. If they say this AI is not ready for prime time, it's possible next week it will be because it will be better than it was.
Robert Wachter:So the evolution has been, the speed of evolution has been really kind of remarkable. Big surprises. If you asked me ten years ago, which comes first? Particularly if the AI gets better, which comes first? I'm gonna sit in the backseat of a driverless car, fall asleep and trust that it'll wake me when I get home, or all of our radiologists are out of business.
Robert Wachter:I would've said the radiologists are toast. I would've said reading a collection of digital dots and saying, this looks like lung cancer, or this looks like pneumonia. That struck me as an easier problem than making a left turn across the Visadero Street in San Francisco. And it turns out that I take a Waymo here about once a week. They're spectacular.
Robert Wachter:And we can't hire enough radiologists in the same city, in the same completely tech obsessed city. So that surprised me. And actually it's a good thing. And the reason it's a good thing is, I'm kind of a student of politics. If doctors or nurses thought their jobs were at risk, they would fight against this and it would block it in healthcare.
Robert Wachter:And we're pretty darn smart. We would not fight against it and say, I'm worried about this taking my job. We would say, I'm worried that this will kill you. And a layperson probably would believe us. And so I think it will take a lot of jobs in healthcare, but the jobs, sadly, each of the people losing their jobs will be sad.
Robert Wachter:But in terms of the political valence of that group of people, it's not the most powerful incumbents. Who is it? It's the thousand people we work and have in the billing department. It's the hundreds of people in the quality department who are flipping through charts, recording data. It's the people drafting and writing prior auths and sticking them in fax machines.
Robert Wachter:We still use fax machines. Those people, I assume there will be some labor savings. When you hear from healthcare leaders, they will engage in the happy talk. That is, we're not laying anybody off, but we normally would have had to grow our workforce this much and it's gonna be flatter, maybe. But I think ultimately, and this turns out to be a big deal because people ask all the time, all right, you're optimistic.
Robert Wachter:Does that mean it's gonna save money? And the answer is, I'm not sure. We are pretty good at figuring out ways of things not saving money in healthcare. New technologies, as surgery got cheaper and cheaper, we do more Lasix on your eyes and hip replacements. So we'll see.
Robert Wachter:But if it's going to save money, the only two mechanisms I can think of, one is labor replacement. One is replacing human FTEs with AI. And the second, at least theoretically, is if it guides us to more cost effective therapies. I could see that happening, but I could also see it guiding us to the therapies that are gonna be the most profitable for the health system or some other actor. So a lot of this has to do with the policy sort of assumptions underlying the recommendations that could go either way.
Robert Wachter:Great. Well, I
Rob Lott:wanna ask you a little more about those policy assumptions, but first let's take a quick break. And we're back. I'm here talking with doctor Bob Wachter about his new book, A Giant Leap, all about artificial intelligence and the future of health care. You alluded to sort of the policy challenges and the the regulatory work that still has to be done, and I'm wondering if you can say a little bit about sort of the principles that you'd like to see our policymakers building on as they shape the rules and regulations around AI and healthcare going forward?
Robert Wachter:Yeah, I mean, like most regulatory challenges, we have the usual Goldilocks problem. You want be nimble and open enough to embrace things that are good and helpful and improve care and quality and maybe lower costs. At same time, not approving something that's not ready for prime time and can actually harm people. I think the structures that we have to insert this problem of AI into are not, as The UK would say, fit for purpose. I mean, the FDA doesn't have the foggiest idea how to regulate a thing that can shape shift as quickly as AI can shape shift.
Robert Wachter:They're trying. They're coming up with different ways of thinking about that. But I think they have a pretty good structure to say, all right, here's a new tool to help read a mammogram or a CAT scan. We know how to certify devices and say whether they're safe and effective. They've come up with some mechanism by which you can say, Well, I'm going to be tweaking this thing.
Robert Wachter:And they'll say, All right, it's certified for now. And if you come back in a year, we have a pathway to get it recertified. What they don't really have is the way AI is going to be used mostly in clinical medicine, is going to be things like chart summarization, things like an AI scribe. Then probably the real money here, and I don't just mean money, I mean also stakes from a quality standpoint, really is in computerized decision support and AI driven decision support. It's even an open question of should they be regulating that?
Robert Wachter:I pick up my phone and use a tool that tells me this patient is likely to have pneumonia or a pulmonary embolism or has a high chance of being readmitted or needing to go to the ICU or the best treatment we recommend for this patient's Crohn's disease is this immunotherapy. But I'm the doctor gonna who's gonna ultimately sign the order in the chart. Is that regulatable? And if it is, why is it more regulatable than the textbook I used to do to do that or the Google search I used to do that? It's really just taking a knowledge base and delivering it to me in a more convenient and maybe more updated and more accessible form.
Robert Wachter:So even there are very big fundamental questions about should they be regulating that? Clearly devices and tools that are high stakes and can kill somebody and particularly where the thing is gonna act autonomously, or even if it's not, the clinician really has no good ability to vet what it's doing like a read of a mammogram. I think it needs to regulate. There it's a question of who does that and how it does that. But decision support, think is really an open question at this point.
Robert Wachter:And then you get to, should it be the FDA? Well, the FDA regulates only the manufacturers of the devices. Whether AI works or not has a lot to do with how UCSF implements it. And so maybe that's not the regulatory framework. Maybe it should be a version of the joint commission that says UCSF is doing the right thing in terms of the way they purchase these tools, has a structure set up to vet whether it's working on day one, convincingly has a structure set to vet whether it's working on day three sixty five.
Robert Wachter:Some have made the argument, David Blumenthal has made the argument that we should be regulating AI like we regulate a doctor. How was it trained? Did it pass the right test? All that. So I think this is a long winded way of saying, end the chapter on regulation saying, basically, I have no idea, and this is a really hard problem and we're gonna need to innovate as much in the way we think about regulation as the way we think about AI.
Robert Wachter:Generally, there's a lot to be learned.
Rob Lott:Great. Fair enough. Well, great fodder for future health affairs content at least. So, I was a regular follower of you and your social media posts during COVID, and, I might describe your vibe in that space as pretty reassuring. You didn't sugarcoat things, but you also found a way to honestly lay out the facts and also shine a light toward maybe hope of better days to come.
Rob Lott:And I'm curious if in your work as a practicing physician, you've had patients confide in you their fear or anxiety about AI and how that might make navigating an already pretty scary healthcare system even scarier. What your response is to someone expressing that kind of fear or anxiety?
Robert Wachter:Yeah, I'm not hearing that much fear, And I'm hearing mostly positive things from patients who are using GPT and tools like it to put in their doctor's notes and say, can you tell me what this means? Or I just went on my patient portal, it says my magnesium's low and my EKG's abnormal. What does that mean? I think they're finding it to be a useful tool to help understand the system, to some extent to navigate around the system. I think where there's fear is something that's about to happen but hasn't happened yet, which is if I take all of my medical record and put it into ChatGPT, which as of yesterday now can happen as ChatGPT just rolled out something called GPT Health, do I trust that it's gonna be kept safe and private?
Robert Wachter:And so I think patients are now already used to, and I think accepting of the idea that my medical record is in digital form, sitting in a cloud somewhere, probably a cloud that Epic is running or whoever my EHR vendor is. So there's nothing sort of fundamentally different about the privacy issue unless you're taking your data and sort of moving it around to different players. I don't know that most patients know that OpenAI or other companies like that are not bound by HIPAA. If they did, they might be more fearful of doing it. But I think you know, I can tell you where So I think most people actually like it and feel like it's making their care better.
Robert Wachter:It informs them before they go in to see the doctor. I think most doctors, I think doctors are a mixed bag on that, but we've already dealt with this. We've already dealt with patients coming with 20 pages of Google printouts. And I guess I'd rather them come in with a GPT printout. So I think it's more likely to be useful to them and accurate.
Robert Wachter:Where the rubber's gonna meet the road here is as patient facing tools get better and more robust. I think most patients are gonna like that and welcome that. To me, some of that's great and some of that's scary because it will give them some things that are really smart and other things that are dangerous. It may convince some of them they don't need to see a doctor when they really do. But you can see just in the last week, Utah just approved that an AI can refill your prescription without a doctor.
Robert Wachter:It's not a big deal because it means a doctor prescribed it in the first place, but you know that that is just the baby step to ultimately AI being able to prescribe. And like all these things, it's a mixed bag. I guess the final mixed bag is deep fakes where, you know, let's say somebody wants to see me as a doctor and I don't have availability. I think pretty soon you'll be able to see digital twin of me that looks like me and sounds like me and says things that I would say because it's trained on me. That sounds like a good thing.
Robert Wachter:On the other hand, you could take a video of me talking to you now and having me say, you shouldn't get vaccinated and you should have 32 glasses of wine a day and it'll look like me. And so, you know, almost all of this is just double edged sword, it can go either way. But I think most patients are pretty enthusiastic about this from what I've seen. Maybe biased because I live in San Francisco.
Rob Lott:Fair enough. I mentioned in the introduction you're considered by many to be one of the fathers of the hospitalist movement. You helped coin the term with a deeply influential New England Journal article published thirty years ago with Lee Goldman. And so maybe to wrap up our conversation today, I thought I'd hit you with hypothetical. How would you, or rather how would your take on the emerging role of hospitalists back in 1996 been any different had today's AI existed back then?
Robert Wachter:That's a great question. Probably not very different. I think in some ways what a hospitalist will do is going to change a little bit, and I would be cognizant of that. One of the things that we did, I think, quite effectively and smartly was to frame the hospital's field as it emerged as being the first field that Remember when we coined the term, it was really in the middle of the managed care era. The IOM report on safety and qualities were just about to come out.
Robert Wachter:And what we did was we framed the field as the first physician specialty that was about not only taking care of patients, but making systems work better. And so I would have pushed the field to completely embrace AI because there's no question in my mind that it's the future, to be leaders in your, to really understand it in a very deep way, to be leaders in your system and trying to figure out how to make this work for your system and for patients, I think that would have been fundamental. What I would not have worried very much about is that AI is gonna take your jobs. And I was in the wards last week, and I've done this the last few times I've been on, I try to use it as much as I can and then ask myself the question, let's say three to five years from now it gets even better and better and better. Do I still have a job?
Robert Wachter:And the answer is yes. The answer is it will take some of the bureaucratic tasks off my plate. It will suggest diagnoses and tee up treatments or testing regimens that I can just click, Yes, I agree with that. But I think people are still gonna want a doctor being the final arbiter. They're not gonna want AI to tell them they have cancer, if God forbid they have cancer.
Robert Wachter:Not gonna want AI to begin chemotherapy, tell them you need to go to the OR. And so much of what I do as a hospital is coordinating really complex teams and who gets involved in what time, decisions where there's no right answer and you've got to sort of weigh different, not only different odds of success, but also the opinions of patients and family members. So I would have been quite encouraging about you're going to have a job, but this thing is gonna be a fundamental part of that job. And you at least, even as a day to day practitioner, need to be good at it. But I would actually encourage some of you to become experts in and to be leaders in it.
Robert Wachter:And I think that would have been fine.
Rob Lott:Great. And good wisdom for for us today as well. Doctor Bob Wachter, thank you so much for taking the time to chat with us today. I really enjoyed it. Thanks so much, Rob.
Rob Lott:Really appreciate it. To our listeners, thanks for tuning in. That was the real Doctor. Bob Wachter, not a deepfake, and, I hope you enjoyed it. If you did, leave a review, recommend it to a friend, smash that subscribe button.
Rob Lott:If you're watching on YouTube, join us again every week, and, of course, tune in again soon.
Robert Wachter:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.