Writing to Improve Patient Safety
Robert M. Wachter, MD is Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and also Chief of the Division of Hospital Medicine and Chief of the Medical Service at UCSF Medical Center. In April, he released his sixth book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, to positive reviews. Dr. Wachter has published 250 articles and 6 books in the fields of quality, safety, and health policy. He blogs at Wachter’s World and is active on Twitter. He coined the term “hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. His 2004 book on medical errors, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes was a national bestseller. He is also the author of Understanding Patient Safety. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google.
Dr. Wachter’s The Digital Doctor covers a lot of ground: policy, the evolution of the electronic medical record, technology, workplace dynamics, diagnostic software, and more. In interviews with people in healthcare, technology, and safety, including Ezekiel Emmanuel, Vinod Khosla, and Captain “Sully” Sullenberger, Wachter explores in detail what he touched on in his widely shared NYT piece, Why Health Care Tech is Still So Bad. You can read an excerpt of his book, How Medical Tech Gave a Patient a Massive Overdose, which I previously wrote about here. After reading The Digital Doctor, I had the opportunity to chat with Dr. Wachter about how he has integrated his deep interest in political science and writing into a successful career in academic medicine.
V: What drew you to medicine?
Dr. Wachter: What drew me to medicine was a little vague. Neither of my parents went to college. I grew up on Long Island in a neighborhood where there were a lot of doctors, and I just thought what they did seemed interesting and important. I liked science, but it wasn’t what drew me to medicine. The disconnect for me was that in college, I found I enjoyed my political science and history classes more than I enjoyed the hard science classes. I liked biology, but did not love chemistry or physics. But I just had this vague sense, without really understanding how this might work, that it would all work out.
V: It’s interesting that you say you wondered, going into medical school, about whether your political science background would ever come into play or not. Do you think you were very intentional about making sure you got to preserve that interest?
Dr. Wachter: No, not at all. I knew the interest was pretty hardwired, but I really thought I would be a doctor, and then I’d come home and I’d just read the paper. I had no idea how one could potentially combine with medicine an interest in the way things worked outside of the scientific understanding of the way people and systems worked. I had role models at Penn Med, and then at UCSF for my residency, who were very well-respected academic doctors and teachers. When I found out that for their research they studied the healthcare system, or healthcare as a business, or the doctor-patient relationship, or ethics, I think that got my mind moving towards the possibility that there was a way of combining my interests. I also got very interested in the role of activism in healthcare because I was involved in planning the international AIDS conference. A lot of what I’ve done in my career is administration and leadership, and in many ways the skills you need to run a large medical service or large division, or chair a national society, aren’t that different from the skills to run a political organization. So political science was dually useful, both as a lens for seeing the healthcare system and writing about it, and then also in helping to inform some of the leadership and administrative work I’ve done.
V: You write so much—you said you’ve written six books, and you also have an active blog—and I was curious how you find the time to write while also doing clinical practice and academic research. Do you have a system where you keep a journal, or you write a certain day of the week?
Dr. Wachter: Those are great ideas, I should really try them! In my earlier days on the faculty, finding a dedicated time was absolutely crucial. I would try to take every Friday away from my office. The only person who knew where I was was my assistant, and she was under strict orders not to find me unless it was an absolute emergency. I went to a little Internet cafe not far from my house and sat there in my blue jeans and t-shirt and wrote for 8 hours. I’m luckily a very efficient writer, and I can sit down and just write for 8 or 10 hours. I don’t keep a journal, but I do periodically keep notes about topics that I think are worth writing about. I was lucky enough for this last book to have a six-month sabbatical that I spent in Boston. In addition to finding dedicated time, I earlier on had some fabulous writing coaching which was really helpful, because being a good academic writer and being a good real writer are very different skills. I also have a wife who is a journalist and a fabulous writer, so that’s helpful.
V: When did you start thinking about writing The Digital Doctor? Was there a certain incident that prompted you to write it?
Dr. Wachter: I really went from an idea to a completed book in a year, which was very fast, partly because I did have six months free to do it, and partly because I ate an immense amount of trail mix to keep me going along the way. But I think the book had been percolating in my brain for four or five years. I’d been waiting for technology to enter healthcare for a very long time, particularly in my area of patient safety, where we’ve held out technology as this massive savior that is going to save us from doctors’ handwriting and giving medicines to which patients are allergic, and all those sorts of things. Over the last few years it did enter our world, and I found myself both disappointed and surprised by how complex it was, and how it was changing our work processes and communication patterns. I found myself pitching stories to my wife, who writes for the New York Times. Then the real story, the day I came home and said “I’ve got to write a book about this,” was the day we gave a kid 39 pills when the right dose was one. Glitches today are so interesting in terms of how humans do or don’t react when technology enters their world. My wife’s very smart and she’s a journalist, and she said, “The only way you’re going to get this right is to do this journalistically.” I didn’t even know what that meant. She said, “You’re going to have to go out and talk to a ton of people.” And that, of course, was immensely interesting. With each conversation, I think I got a little bit smarter about the topic and themes began to emerge, and little light bulbs went off and made clear what my direction was.
V: What do you see as the future for physicians who want to remain physicians but also have a voice in changing the way things are done?
Dr. Wachter: We have recognized that in American medicine, we are not producing care of particularly high or reliable quality, safety, and patient experience, and we’re doing so at a cost that’s going to bankrupt the country. To make all of those things better, we need people who really have deep understanding of a lot of things that I learned nothing about in medical school. I had learned nothing about systems, process redesign, cognitive psychology, information technology, or the political aspects of getting work done. We need everybody—nurses, doctors, pharmacists, others—who are training for clinical roles to have at least some understanding of that world in order to inform it and participate in it to the degree possible. There are a lot of people like me who are not full-time clinicians, but do enough clinical work to inform their worldview, and have become experts in things like IT, quality improvement, efficiency, and so on. I think we’ll need all of those people. It is really important to have people who can be spanners. It’s a very exciting trend in medicine now. When I was in medical school, I considered myself and was considered by others to be an oddball. But now I think there’s a recognition that we need some people that really do think about the system and some of the non-clinical aspects if we’re going to get this right.
V: What kind of reaction have you gotten to the book? Have people taken steps to prevent technology-enabled errors in the future and to try to change the system?
Dr. Wachter: My main goal was to help create a national conversation about this, and I think that is happening. One change has happened at my workplace. I write in the book about how, here at UCSF, our residents go to their own office to do their work, and it happens to be about five floors away from where the patients are. People read the book and heard me give talks about this, and we all basically said, “Why don’t we move that room next to the patient floor? That’s where it needs to be.” So we did that. People also read the chapter on radiology and said, “That’s right, we used to be able to round with radiologists and we’re not anymore. How do we recreate this relationship? There was so much value there.” That was really my goal, to get people thinking hard, to not just accept the status quo. I don’t think you have forever to get this right. Younger generations don’t actually know what radiology rounds used to be like. If you wait too long, people even forget it was a possibility. We actually have a lot of control over our destiny here, we just have to begin thinking about the work in a new way.