The incomparable Bob Wachter

Daniel sat down with Bob Wachter to talk about the power of Twitter in public health, the continued evolution of patient-centered digital transformation, the very necessary adjustments to clinical education, his personal history as the founder of the hospitalist movement, and which technologies continue to lag in our industry.

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Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Dr. Bob Wachter:
How do you think about this nature of this job that you have of the patient as a whole person, the patient as a member of their community. A patient whose outcomes and the way they process information may be very much determined by where they live, and their family situation, and their economic status, and all of those things.

Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft and today we're really lucky to be in healthy conversations with Dr. Bob Wachter, the chair of the Department of Medicine at UCSF, one of our really preeminent medical schools. He has a long history as a healthcare thought leader, innovator from the future medical education and beyond.

Dr. Bob Wachter:
It's great to see you.

Dr. Daniel Kraft:
You've had a somewhat unique career path after medical school at University of Pennsylvania, came up to California. You are one of the founders of the hospitalist movement in the mid-90s. Can you share a little bit about your journey, how that movement started and where it's gone next, and even move from hospital to home, or homespilist?

Dr. Bob Wachter:
I'll try to keep it brief, because I'm an old guy so this could take a while. I'd say the defining conceit of my career was I was a political science major in college and I tell people I'm what happens when a political science major becomes a modestly successful academic physician. I have always been interested in the way the healthcare system is organized. It relates to something pretty close to the ground. It relates to the way we take care of patients in real life. What it does as a system to achieve the highest quality, safest, least expensive, most satisfying care. It doesn't do that very well.
That has led me over my career from studying activism in the early years of AIDS and the role of patient advocacy groups, to thinking hard about the organization of hospital care, and that led me to coin the term hospitalist, to thinking about patient safety and quality. Then about seven or eight years ago inspired in part by people like you got really interested in the digital transformation of health care and why it was so bumpy when my iPhone's pretty easy. Over the last two years it's been COVID.
The hospitalist thing happened, because in 1995 I was asked to become chief of the medical service at UCSF. I had a boss, Lee Goldman, who's a visionary person who said, "The medical service is organized the way it was when I was a resident here 25 years ago. That can't be right. Let's think of a different way of organizing inpatient medicine." I began snooping around thinking who's at the head of the curve here? I was inspired in part by the evolution of emergency medicine and critical care medicine to fields that had emerged a generation earlier that had the same attributes. Generalist fields that really are specialists in a place. I think hospital care is going to evolve fairly quickly.
The concept of hospital at home was introduced 30 or 40 years ago. Pretty good evidence that it works well. Patients like it better, costs are lower, and yet it's gotten almost no traction in 30 or 40 years, because economically it's tricky and logistically it's tricky. Right now, if it's admitting a patient to the hospital, it's one phone call to the admitting team. If you want to send the patient to hospital at home, it's probably 12 phone calls. Including to the oxygen company, and the telemedicine company, and the this, and the that. I think, that it has hit a tipping point now and you see companies emerge in that space where, I think, probably 10 to 20% of patients who are currently in hospitals could be taken care of better than and less expensively than they are now in hospitals if we can figure out the logistics and the finances of hospital to home.

Dr. Daniel Kraft:
You've been such a leader in health education. You ran the residency program at UCSF for medicine, as well. How we care for folks in these blended modalities, partly catalyzed by COVID, does that need a shift in how we educate our caretakers?

Dr. Bob Wachter:
It doesn't feel like a sea change in the way we interact with patients. Yeah. We need a little bit of new education about telemedicine. I think, the big deal is does the overall paradigm of how we deliver patient care change? We are now gathering data semi continuously. We're somehow processing it in a way that doesn't overwhelm the system, that's a non-trivial problem. We are interacting with you in whatever way works best to improve your care and your health. That's a big heavy lift. A much heavier lift than just shifting a 15 minute to zoom rather than in person.
If that happens and, I think it will, then the shift has to not just be website manner. The shift has to be how you conceptualize the role of a physician. How you think about this whole team of people including health coaches, and NPs, and PAs and nutritionists and others. Also, this other member of the team called artificial intelligence, because if all this data is streaming out of someone's watch or their scale or their... I saw a company got 30 million for their digital toilet. Periodically, I'll hear people talk about how wonderful this is going to be. I've got 300 primary care docs who work for me. If I tell them that you're getting that data flow today they will quit by five o'clock this afternoon. That requires a huge remodel of the health care system and a major change in what a physician does for a living.

Dr. Daniel Kraft:
The connected toilet gives new meaning to health streaming data as it flows.

Dr. Bob Wachter:
Yes.

Dr. Daniel Kraft:
To that point, as you mentioned, no clinician, primary care specialist wants the raw data from your wearable or genome, but which is still a big barrier. You wrote a great book, The Digital Doctor, some of the unforeseen circumstances that have evolved from the digitization and connected to mobile health.

Dr. Bob Wachter:
I wrote the digital doctor now about seven or eight years ago and I did it, because I was really flabbergasted by how hard the implementation of technology was in healthcare. I'm as wired as anybody else, maybe not as wired as you, but I believe in technology. I believe in the promise of it. I saw even the first step, which was really the movement from paper to electronic medical records was incredibly fraught with unanticipated consequences. Doctors not looking patients in the eye anymore, because they're so busy being pretty unhappy data entry clerks. More subtle things like we used to go down to radiology to talk, to look at our film. Now, it's a digital image, you could see it anywhere. We lost our connection with the radiologist that we used to have.
I think, we're now at a much more advanced stage. We've gone far beyond the electronic health record, but I think the electronic health record teaches us something. What it teaches us is if you don't think hard about the end user, about the experience of the patient, the experience of the doctor, the nurse, and others, and you come at this with a sort of tech first mindset you'll get it wrong. For physicians we're spending an enormous amount of time entering data into these machines and we get amazingly little useful intelligence out of it. Whether it's decision support or predictions.
The same thing is true for patients. We have now enabled patients digitally. They now have their portals, they now see our notes. They get a cardiogram and it says abnormal cardiogram. Of course what are they going to do? They're going to message their doctor and say, "What the hell does that mean? Is that something I should be worried about?" the doctors are underwater. I think, we developed a way of patients connecting with their clinicians without giving a moment's thought to what is the economic, and the workflow, and the workforce model to manage this.

Dr. Daniel Kraft:
Some have used the term digital empathy, those connection points between patient and physician.

Dr. Bob Wachter:
Medicine's a really complicated industry, I think, more complex than most other industries that we've digitized. I don't know how much human connection you need to get a prescription for antibiotics for bronchitis. I think, there's a fair amount of stuff that really is pretty algorithmic that if you had the right data, the right inputs, patients could get it in a way that feels far more transactional than we're used to. I think, for those of us as physicians it bugs us.
Can a bot or AI delivered to them the news that they have cancer? Or here's the implications of their chest pain? Or whatever. I don't think so. What's hard about this is in the old days patients only had one way of accessing the credentialed expert, which was to go see the doctor in a physical space, in this thing that we called an office visit or an ER visit. To parse this well so that the things that are done in a pretty algorithmic and transactional way, which will be cheaper, are the right things, but when you actually need a human connection you get it, I think, is a pretty tricky thing to work out. I don't think we've even begun to think that through in a way that we're going to have to in order to get it right.

Dr. Daniel Kraft:
Yeah. It brings us into the need for sort of design thinking and not just precision medicine, but the precision user interface. Whether you're a Baby Boomer or a Millennial you might interact with your clinician in very different ways. Has this, given your experience having been the residency director at UCSF Medicine, changed the way you think about medical education?

Dr. Bob Wachter:
I think, it does influence the nature of education, because the idea of the doctor as the expert, the font of all information and a very hierarchical relationship where the patient doesn't know very much and the doctor will tell the patient everything he or she needs to know. That was a notion during my training and it's not no longer going to be the way healthcare works. Digitization always democratizes things. The patients always did come in with their own ideas, and preferences, and biases. I think, we undervalued those up until 10 or 20, 30 years ago the doctor really was the only source of information. Now, the patient has myriad sources of information. Patients may come to the table knowing as much about their problem as you do maybe more. Sometimes they have access to craziness. They have very little ability to dissect, figure out which one is which. That leads to challenges where patients may come in armed with information that's wrong or misleading and they may be quite wedded to it.
We're not used to having a lot of confrontational relationships with our patients. One of the challenges I've heard during COVID the physician then had the job of trying to correct that. That's not an easy thing to do. You're initially, "Who are you patient to be questioning me?" I certainly have seen doctors like that in my career. Now, if that's your attitude you're in the wrong field. You have to come in assuming the patients have thought a lot about this, assuming they've looked up whatever they have on Google beforehand. Some of the time it's wacky and you're going to need to figure out a way of dissuading patients from some information that they thought was credible.

Dr. Daniel Kraft:
Yeah. You played a major role in social media. How do you translate complex enough and moving science to a patient who may have access to the entire compendium, as well as misinformation.

Dr. Bob Wachter:
Health communication's always been a core part of our job, but the playing field has changed massively. I have a daughter who's a fourth year medical student at UCF now, so I've been watching her evolution as a physician. It's fascinating, because it really is going from novice to expert. The scenarios that one might have given you or me 20, or 30, 40 years ago, which is the patient comes into your room and you make your proclamations and they say, "Thank you, doctor." Those are not the scenarios anymore. It's a much leveler playing field.
I think, some of the things that have changed, probably, even more than the communication is a much deeper appreciation of the issues of health equity, disparities, and the social determinants of health. I think, I learned precisely nothing about that. Maybe, there was a nod to it in one lecture in epidemiology that it turns out that much of how patients has more to do with where they live and their socioeconomic status than any medicine that we might give them. Now, I think, it's being integrated much more into their training. And training is two things, really. Training is facts and approaches, but a lot of it is enculturation. How do you think about this nature of this job that you have, of the patient as a whole person, the patient as a member of their community, a patient who's outcomes and the way they process information may be very much determined by where they live, and their family situation, and their economic status, and all of those things. It's an exciting phase, but working through it is very different than medical education 30 years ago.

Dr. Daniel Kraft:
Twenty-something years ago when I was a Stanford med student I was in the ER with a resident named John Halamka, we're the only two geeks carrying around at Hewlett Packer 200 LX. We had a little bit of a health compendium and a little bit of an advantage on rounds. Do you think the future of our EMRs and charting will include the sociom, and the connectome, and metabolome? How do they start to educate themselves more on this sort of sociom and other layers that are becoming continuous?

Dr. Bob Wachter:
I think, you're raising a really important question, which is I can understand that the patient's situation and clinical presentation is influenced by their housing status, or their economic status, or racial ethnic differences and still feel, "All right. What do I do about this?" It's much easier to prescribe a pill. I think it's an appropriate question to say what about all this stuff is actionable? It may be that you can't do anything about the patient's poverty, but if you don't appreciate the patient's poverty, and its influence on their outcomes, and their ability to take the medicines you're prescribing, and get the medicines you're prescribing. If the healthcare system ultimately doesn't rejigger itself to account for those things, particularly, if the payment system changes as I hope it does to a system in which we are paid in part based on the outcomes of patients.
That will provide a greater incentive than we have now for our systems that may be more social workers and fewer doctors. It may be that we actually are investing in sort of understanding the community now in different ways and being able to reach out to patients in different ways. It's very tricky. Periodically, I'll hear about a healthcare system. We understand the importance of socioeconomic predictors, so we're beginning to work on building housing. My instinctive response to that is we barely know how to deliver health care effectively. What makes us think we're going to be any good at building housing? This, I think, is mostly going to be partnering with organizations that actually are in those spaces to help patients in new ways.

Dr. Daniel Kraft:
In terms of meeting patients where they are some examples of using blood pressure screening in the African-American barbershops, all the way to they have a data plan and access to wifi, et cetera.

Dr. Bob Wachter:
Once you build the thing even if you're building it for well-to-do people the cost then of making it available to people who they can't afford it, but scales very cheaply. Then it just is payment system 101. If your payment system somehow has to cover the cost of a wireless plan for a patient on Medicaid. Your alternative is because you're not treating their blood pressure and their diabetes effectively they're in your ER every other month. It's a no-brainer that you would be far better off paying for their wireless plan. If you take a poor person and you say "For $500 a year I can give them the digital capabilities that allow them to access the right specialist for their problem and that would decrease the probability they're going to get sick, be hospitalized, go to the ER by 50%." I'm guessing the ROI on that would be massively positive. It's a question is the system spar enough to create a payment model and then a way of moving money from one column to another to allow that to happen? I think, that's likelier than not to happen.
One of the amusing parts is, I think, about how people react to the COVID. Look how it exposed these disparities in healthcare like they were new. The outcomes for cancer, if you look at life expectancies and wealthy zip codes and poor zip codes they differ by 20 years. We've known about health disparities forever. I think what happened is during COVID, in part, because of George Floyd, people paid attention to it for the first time. When they pay attention to it they realize it's unconscionable, and unethical, and that you could fix a huge number of them if it's targeted well. If you create an incentive for entrepreneurs it doesn't strike me as that hard a problem to solve.

Dr. Daniel Kraft:
What have you noticed in terms of your colleagues at UCSF and beyond in terms of clinicians of today or healthcare workers getting more involved in the social side?

Dr. Bob Wachter:
Well, there's absolutely no question that the kind of activism and social consciousness around issues of health equity are far more on the radar screen of physicians today and institutions today than they were before. I'm very proud of UCSF in this regard, but we're being pushed more by our junior faculty, and by our students, and our residents. For many of them this is a defining issue in their career. They went into healthcare, in part, because of issues of health equity. Our medical school is about 50% from underrepresented groups in medicine. Our residency is about 30%. The healthcare system has to build in a financial model to attack these things with the passion and the fervor that people bring to the table.
I think, that's beginning to happen. I think, you can very easily get stuck in lip service and everybody's saying all the right things, but then the real hard questions are what do you actually do practically and where do you find the resources to do it? I have to say that's a little bit of a concern I have, because for the last 20 years I've been very much in the middle of the patient safety movement. That was a movement that was energized by a report that came out in the Institute of Medicine about 20 years ago saying we're killing close to a hundred thousand people a year from medical errors. The amount of energy and resources going to patient safety, I think, has gone down. In part, because there are these other imperatives. How do we create a balance that does what we're here to do, which is improve health for all of the people that we're taking care of.

Dr. Daniel Kraft:
I want to zoom out now to where we are today in 2022. I'm one of at least 250,000 of your devoted Twitter followers. First of all, thank you for the amazing job You've been doing it synthesizing so much complex information. What's that been like for you?

Dr. Bob Wachter:
Well, my wife is sick of it, because every time she comes downstairs I'm doing a TV or radio interview. I was leaving the house to go to the wards and I said, "Bye, honey." She said, "Oh, I'll miss you." I said, "Oh, you don't have to. I left the Rachel Maddow tape on the VCR." She said, "Get the hell out of here."
I was on Twitter before. I liked it. I probably had 15,000 followers. When COVID hit I had a sense, first of all, this is going to be the most important issue in the world. Huge numbers of lay people are going to be trying to keep track of everything. I like thinking big picture. I like being a synthesizer. I thought there might be a role of some people who pulled a lot of different threads together, processed it, made sense of it, and then put it out to people in a way that was accessible to them. It turns out that was right.
My following went from 17 or 18,000 to 260,000. It's a big responsibility. In the last six or eight months I've found that my particular lane has been not only to synthesize it, but to say to people here's what I am doing. Here's how I am or I'm not wearing a mask. I am or I'm not traveling. If I am here's the mask I'm wearing. I think, for a lot of people that was useful.
I found that the response from the Twitter community has been almost entirely positive. My world, when I tweeted about my younger son's case of COVID a couple of months ago. One day I tweeted, "I love him to pieces, but I wouldn't want him to breathe on me." All of a sudden I got this storm of people saying, "You are a terrible parent." There's nothing that would cause me not to want my kid to breathe on me. I think it's been an amazing way of keeping myself educated and then it's been extraordinarily gratifying to feel like people are taking advantage of what know. There's so much uncertainty.

Dr. Daniel Kraft:
Incredibly important, because it is full-time or more than a full-time job to try to put it all together and make it locally contextual. My wife says, "Oh, Dr. Wachter tweeted this." Or "Dr. Topol, did you see that?" I'm like, "Yes, but I didn't tell you about it." You're often head of the curve. You also had a run a guest hosting The Bubble. One of the biggest podcasts in public health, which Andy Slavitt was working on, but took a sabbatical while we were at the Biden White House. Any highlights on doing a podcast version?

Dr. Bob Wachter:
Everybody complains about the modern media environment, but most of what I've learned about the pandemic has come from Twitter. Not just from Twitter, but seeing Eric Topol cite an article that I would not have seen and then going and reading the article. As you know from doing this. The podcast world is a different version of this. A very democratized way of accessing the brains of people who you find interesting and with a wonderful host like you asking really good questions. When Andy called me and said, "Can you sit in for five months while I go to the Biden White House?" First of all, I was incredibly gratified and touched, but I just thought, "What a great platform." The ability to think really broadly about what are the key issues that people need to understand in order to make sense of this thing was really a pretty cool opportunity.

Dr. Daniel Kraft:
Any silver linings that you see from the pandemic, both in terms of the communication side, the medical, the technology angle?

Dr. Bob Wachter:
I talked to your old friend, John Halamka, actually, I had interviewed him for The Bubble and was asking him that question. He gave me this wonderful example. He came to the Mayo Clinic for this new job when he left Harvard a month before the pandemic started. He said he was handed the 2030 Mayo Clinic: A Digital Plan. He said by the end of 2020 it was done. Basically, they took 10 years of what they thought they would do and shoved it into a year.
I have an abiding belief and I think you do too, that medicine will ultimately be improved tremendously by digital transformation. From being a thing that happens only in a visit in a space that we own to something that's much more ubiquitous, much more patient-centered. It's going to be bumpy and they'll be unanticipated consequences. The faster we go, the better it accelerated. The emergence of really effective dashboards and data visualizations. I can go online and in 10 seconds look at the UCSF COVID report that shows me how many people are in the hospital, in the ICU, how many are with COVID versus for COVID, how many are testing positive with symptoms without symptoms.
Never had access to anything like that before. Five years ago, three years ago if I said, I want all this information somebody would've sent me 12 spreadsheets, which, of course, was worthless. I don't think artificial intelligence moved as fast as I thought it might. The thing that definitely did accelerate, which will push it along is the labor shortage. Even if you think you can afford to solve every problem with a yet another nurse, or another NP, or another PA, or another doctor you're probably not going to be able to find them. You're probably not going to be able to hire them and keep them.

Dr. Daniel Kraft:
We've also accelerated the burnout. It's the third or fifth wave, the mental health challenges, and others, and the shortages that have been exacerbated by the pandemic. Any sort of solutions or hope?

Dr. Bob Wachter:
I think, there is a tendency in healthcare delivery organizations to see nurses or doctors complaining and saying, "Oh, they're just whiny." I think through COVID there was a much deeper appreciation of the toll that delivering healthcare was taking on frontline workers. Burnout is not a moral and ethical problem. It's a business problem. If you have unhappy workers you're not going to be able to have A) enough of them and B) you're not going to have happy patients.
My organization has done much better than it used to. First of all, we survey people a lot and the surveys are decisive. When we see our net promoter scores not where we want them to be that becomes like number one on our strategic plan. For example, this digital inbox issue really surfaced as a problem in the past year or two. When we looked at our net promoter scores what do doctors and nurses want? They want to be taken care of people. They want to be operating at the top of their license. They don't want to be doing things that are clearly algorithmic. I think, raising it is a problem and demonstrating healthcare organizations how important it is to participate in fixing it, I think, is a very positive trend.

Dr. Daniel Kraft:
With this explosion of digital solutions somewhat catalyzed by COVID it's often still about the incentives, because it's one thing to have it on the formula, it's another thing to use it.

Dr. Bob Wachter:
I think, it's a really hard problem and I think you're right. It has to be integrated into the payment system. The problem is people say, "Well, value-based payment is just around the corner," but they've been saying it for 25 years. If you look at a system like mine our incentive is still to take care of sick people. We have more business than we have capacity for. If you are dependent on a system like mine to make an enormous investment in people doing care at home so that they keep themselves healthy the existing payment system does not provide that catalyst. I'm old enough to have seen a lot of statements that value-based care is inevitable, the cost of healthcare is unsustainable. Now, I'm old enough to remember when people were writing that when the cost of healthcare was 11% of GDP, not 18% of GDP. Clearly, they were wrong, because it not only got sustained at 11%, but it went to 18. I don't know what the catalyst will be to move toward a system that is more value based.

Dr. Daniel Kraft:
Totally agree. I think, one of the challenges is that there's many different healthcare systems and some are doing this quite well and others aren't. NHS has some great examples, technologies out of Israel where you can buy in, and align incentives, and the ability to integrate this into the workflow and it's not pay per widget. What would you like listeners to know about what's possible?

Dr. Bob Wachter:
Well, I think, one of the things that I find most interesting about the current era is the last 5 to 10 years in healthcare digital were really dominated by the electronic health record. It's hard for people to remember this, but in 2008 fewer than one in 10 hospitals, one in 10 doctors offices had an electronic health record. The system was entirely paper-based. Now, fewer than one in 10 does not have an electronic health record. To me, we're entering a very exciting, what I think of as a post electronic health record era.
Much more diverse set of tools. A company building a tool for diabetes, or for emphysema, or for hypertension. The challenge there, of course, is then integration. Patients don't have one problem. They have five, and they're not going to be using five different tools, and they're not going to be signing on to five different places. Somehow all these things have to then weave together into something that feels integrated and one home base for patients and providers. I think, we're in a much better place than we were five years ago when we were really thinking about this big monolithic enterprise tool as being the be all and end all.

Dr. Daniel Kraft:
With that, Dr. Bob Wachter Chair of Medicine at UCSF. Thanks for all the amazing work you've done and that you are doing. Really appreciate you joining us today on Healthy Conversations.

Dr. Bob Wachter:
Thank you for the opportunity, Daniel. Great to talk to you.