OP-ED

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande

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Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.

Once we’ve recognized the recipe for really great performance, the second thing we’ve discovered is that our most important resource for improving the ability of teams to follow through on those really critical things is data. Information is our most valuable resource, yet we treat it like a byproduct. The systems we have – Epic and our other systems – are not particularly useful right now in helping us execute on these objectives. We’re having to build systems around those systems.

The third insight is that, for the most part, the issues have less to do with systems than with governance. The people who are buying these systems, installing these systems, and determining how they’re to be used… What are they responsible for? What are their objectives? We’re having to figure out how to get quality and outcomes higher on the list of priorities of everybody running health systems.

Our dumb checklist, or our incredibly sophisticated predictive analytics algorithm, or that incredibly expensive EHR system… none of those change that fundamental failure – the failure of governance. And none of them can, no matter how you design them.

Gawande raised the example of hospitalists. He asked me about my group at UCSF, which has – by focusing on performance improvement as our core mission – become a key innovation engine at our institution.

AG: I think your hospitalist example is really important. Over and over again, it’s the pattern I see: a powerful idea creates a momentum of its own. When you’ve shown that there’s an obvious better way to take care of people. It’s controversial, and hospitalists can be used in ways that destroy the original intent. I’m sure you think about this all the time.

But when it works, it forces the leadership change. Leadership didn’t create hospitalists. Hospitalists created leadership. I think that’s the way it happens.

The same kind of thing happened with anesthesia. People didn’t say, “Oh, we have to find a better way to manage the pain of patients, because surgery is causing horrible suffering.” Somebody came up with an idea, and demonstrated that you could relieve this problem. But it required incredible system change. You had to double the number of people working in operating rooms at a time when the United States had a lower GDP than China does today. “We’ve got a better way of doing surgery. Oh, and it will involve doubling the number of physicians you have providing the care?” Is that a great model? It was dismissed as totally non-viable, can’t work. But it didn’t matter. It was too important, and it became the driver of leadership change, rather than the other way around.

A similar thing happened with Paul Farmer. There were debates for a decade about whether you could treat HIV in poor patients. Oh they don’t have watches, they can’t take the drugs, they can’t do this, they can’t do that. Farmer is like, “Fuck it!” I am going to Haiti, and I’m going to do it in a little old clinic in the middle of nowhere. And no, they didn’t change a whole country … but they changed a paradigm.

I think that’s the cool thing, that it’s not the technology. It was the values and the core idea that demonstrated you could accomplish this, that got you there.

I asked Gawande a question I asked most of my interviewees: Will computers replace physicians?

AG: The variousness of the healthcare world is pretty extreme. When we look at the way that disease presents itself, we’re moving increasingly away from science. When it turned out that lung cancer is not one disease, but rather that it’s four or five different histologic subtypes, that made it more complicated. Now we know there are 47 – and the number is growing – genes that, in different combinations, govern the behavior of those cancers. Forty-seven genes, and then you look at the multiples of different ways that people have these genes. Now we learn that the epigenetics and the expression of those genes are incredibly dependent on the environment. Did they smoke, how did that affect the genes? Did they have any kind of industrial exposure? How old are they at the time that the cancer appears?

Our cells on our little Excel spreadsheets are getting smaller and smaller and smaller. We’re getting back to the world of the 18th century “art of medicine,” where everything is becoming an “eyeball test.” The danger is that it becomes actually increasingly data-free – that every single person becomes a case of one. That becomes impossible to learn from. Period.

Where we’re moving, I think, is towards saying, “I have a class of people. I’m going to try Process A on this class of people who have some combination of these different genes,” and stuff like that. And then, does that process lead to better outcomes? The processes will be things like, “I’m going to watch them for three months. Then if X happens, I’m going to do an operation. If Y happens, I’m going to give them chemotherapy.” That increasingly becomes the way we learn.

RW: In your work as a physician, do you think care is getting better or getting worse?

AG: I think it’s massively better.

RW: Why?

AG: It’s fundamentally because of values, more than technology. I think we’ve changed our values over time. That patient suffering matters. I remember as a surgical trainee, I was expected to inflict levels of pain that today are just not acceptable. In my first month as a resident, I went into an operation to do a rib removal on a young girl. I’d never done one before; I had a month of operating experience. A fellow was standing at the door in his scrubs, saying, “Yeah, yeah, yeah, cut there.” The attending is in another room. I didn’t know what the hell I was doing.

The culture was, even to suggest that was a problem, meant you were weak.

Gawande asked me how I perceived the training environment today – particularly the tension between the patient and the technology.

RW: The residents’ instinct about teamwork is much better than mine was. I mean, the idea of my caring about what the nurses thought just wasn’t on my radar screen. And the residents’ instinct to get back to the bedside – when they’re spending all their time on the computers, they feel this loss and I think they’re trying to reconnect with their patients. We’re trying to create structures to allow that to happen.

But it’s hard – the residents feel they’re caught up in this world where everything they need to know is on the computer screen. That’s creating angst in their day-to-day life. You go up to the floor of the medical service in my hospital, and there are no doctors there. They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work. That means that many of the informal interactions that used to occur between the docs and the nurses, or the docs and the patients and their families, have withered away.

AG: Everything that they’re measured on and that defines their success happens outside the patient’s room.

RW: Correct.

AG: There’s a difference in surgery training. Everything that you’re measured on and that matters happens in the operating room. Although the patient’s asleep, the residents are having to work on their people-to-people interactions. How do you handle yourself with the nurses? How do you handle yourself with the doctors? What are your skills? They’re trying to figure it out and navigate it. It’s often a complete mystery to the students, and for a long time to the residents, too.

But except in the most egregious cases where you really piss off a patient, their success – being labeled an A versus a B – relates to “how much do I really know this patient?” It’s not getting my to-do list done for the day. Yet getting through the to-do list is the dominant task.

And we’ve both contributed to discoveries that indicate that all these little steps on the to-do list matter. It’s become an endless list of details that really, really, really matter. Do you have the right combination of antibiotics? Is the head of the bed at 30 degrees? When I think about the to-do list that I had when I was an intern, and the to-do list that the residents have today – today’s is just massively longer.

I closed by asking Gawande about the concept of the Quantified Self – patients wearing sensors and accumulating all kinds of personal data. While he is generally supportive of the concept, he has a concern, one that echoes the central theme of Being Mortal.

AG: I worry that we could become tyrannized by a combination of experts and sensors that have no close relationship to our priorities. That’s why I just keep coming back to the values. We’re here to alleviate suffering. I think it’s about this deeper connection we all have to something important.

Robert M. Wachter, MD is Professor and Associate Chair of the Department of Medicine at the University of California, San Francisco, where he directs the 60-physician Division of Hospital Medicine. Author of 250 articles and 6 books, he coined the term “hospitalist” in 1996 and is generally considered the “father” of the hospitalist field, the fastest growing specialty in the history of modern medicine. He is past president of the Society of Hospital Medicine (1999-2000) and past chair of the American Board of Internal Medicine (2012-13). In 2004, he received the John M. Eisenberg Award, the nation’s top honor in patient safety. For the past seven years, Modern Healthcare magazine has named him one of the 50 most influential physician-executives in the U.S., the only academic physician to receive this recognition. In 2014, the same publication also recognized him as one of the 100 most influential people in healthcare. His new book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age, will be published in April, 2015.

He blogs regularly at Wachter’s World, where this post first appeared. 

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ThomasJohn BurchcivisisusMike-TruelifefitnessMike Painter Recent comment authors
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John Burch
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John Burch

I’m sorry to have to ask, but what was Gawande’s actual answer to the question, “Will computers replace physicians?”

Whatsen Williams
Guest
Whatsen Williams

Why did you repeat this stale cookie? I like Emma’s comment.

Mike-Truelifefitness
Guest

Great article. People are definitely looking to the internet to make their own diagnosis

Mike Painter
Guest

“We’re having to build systems around those systems.” Check your irreverence at the door, Mike –and I will. Still, I can’t help it. Aside from the well-placed f-bomb, that’s my favorite line in this post. Assume that the “he wryly noted” was implicit. I am a sucker for smart physicians writing passionately and well about their craft as both Drs. Gawande and Wachter do here. I also love the essentially optimistic outlook—Dr. Gawande observes that care is “massively better” these days. We all sincerely hope that’s the case. It’s of course hard to argue with advice that we should focus… Read more »

Emma Thomas, RN
Guest
Emma Thomas, RN

Confirms that EHRs are dangerous impediments to the safe and efficient care of patients, as has been my experience. Wachter and Gawande have residents and scribes using these systems and could not enter admission orders if their lives depended on it.

John Ballard
Guest

I’m sure there are compelling arguments for and against EHRs but your ad hominem attack on these two men is way out of line. That comment embarrasses me on your behalf. You have reading and homework to do.

@BobbyGvegas
Guest

Indeed.

jordan
Guest
jordan

Healthcare is a people profession. As long as people are patients, it will always be about people. The checklist is to make sure that people did/do the right things, the ‘what matters to you’ is all about humanity. Simple stuff.
I completely agree that there is no accountability at the top (governance) regarding what happens at the bottom. The 30,000 feet people need to stop acting like they know what’s going on at the Ground Floor….and the need to listen to them. The problem here is that we have an egosystem, not an ecosystem.

Chris Kapsa
Guest

Egosystem! I love it!

John Ballard
Guest

Great post. Two of my favorite people, Drs. Wachter and Gawande. And I’m two days late finding this. (I need to check in more often, but those tedious spam alerts annoy me.)

Michael Millenson
Guest

An important interview. Thanks, Bob and Atul. Particularly important is the emphasis on organizational elements and outcomes (e.g., Farmer’s accomplishments), with technology as the handmaiden. It’s also important to understand, as I know you do, that digitization that allows access to information has important consequences, as well. Web access to infection rates at a particular hospital, for example, won’t “replace” doctors, but it does replace the professional monopoly on information with a model of information that’s very accessible to the lay public. (Whether that’s health plans, competitors and lawyers or patients using it isn’t really important.) In this sense, the… Read more »

Chris Kapsa
Guest

Gawande’s book is marvelous. But it did strike me that he had no new answers. In a way, how could he? There aren’t any. Yes, knowing what one wants at the end of life, understanding your values and so forth are helpful. But those are not answers to the fundamental issues of how society manages to give this care. Gawande knows that. I am not familiar with Wachter’s later work. The seminal Wachter/Goldman article gives short shrift to patient satisfaction. It may, in part, have set the tone. Then, this being the US system, anything that can be monetized, is.… Read more »

Charles Kenney
Guest
Charles Kenney

Chris I appreciate your comments and I am sorry to hear that you recently lost your mother. Please take care.

Chris Kapsa
Guest

Thank you, Charles.

Charles Kenney
Guest
Charles Kenney

Is there something of an underlying theme in some posts that Gawande and Wachter aren’t quite as patient focused as they should be? Gawande’s books — Being Mortal in particular, are about as patient-focused as you can can get. The stories are one after the other, told with great care and empathy about particular patients. I also have to disagree with Chris K a bit suggesting that Gawande sees the probs but doesn’t have answers. The way Being Mortal struck me was that it led inexorably to the question — for each patient in a later or challenging stage of… Read more »

Chris Kapsa
Guest

Seems, Grandpappy, you doth protest a tad too much. Never said all, never said anti-physician. You’re trying to read more into my comments than is there. Have you read the Wachter/Goldman article? It’s instructive. I’ve no doubt there are compassionate, skilled and overworked hospitalists. But it’s a system they’ve chosen. One that permits a certain type of medical practice without the messiness of forming long-term relationships with patients and families. Just as ER medicine, radiology or pathology. The key difference is patients don’t expect wholehearted physician engagement in those specialties. Hospitalized people (perhaps with exception of elective noncancer surgery) are… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“Hospitalized people (perhaps with exception of elective noncancer surgery) are in crisis. They need care from physicians who they trust and know. Hospitalists are strangers, by definition. No matter how compassionate, that’s a yawning chasm.” Agree completely. I’m not a hospitalist, and I don’t like the hospitalist system. But it is here, the inevitable and completely predictable result of the corporate takeover of medicine that both patients and physicians have allowed. If you don’t like it, go after the system and those who profit from it. Attacking those who, like you, are trapped in it is like caged mice devouring… Read more »

Chris Kapsa
Guest

One is only trapped by choice. Unless all of us in this godawful system start saying, “We’re mad as hell and we’re not going to take it anymore”, it will only get worse. We’ve all become the means of production to some one else’s income. Physicians have ceded control of medicine bit by bit. First it was for more money and a better “lifestyle”. But that was a bargain with the devil. Now only the most frenetic proceduralists make real bank and everyone’s lifestyle sucks. And patients suffer. Don’t even get me started on what’s happened to nursing, my beloved… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“Suppose one group of highly respected IMs said, “Dammit, we’re going to hospitalize our own patients”. Told hospital management to take it or leave it.” Great. And suppose a group of highly respected patients and employers went to their insurers and said “We want you to only contract with hospitals that allow private physicians to manage their patients, and that allow patients their free choice of consultants. And we want you to fairly pay physicians for their time, so they can talk to us and manage our care, both in and out of the hospital. Take it or leave it”… Read more »

Chris Kapsa
Guest

Thank you. We talk about patient engagement with BP monitoring and Fitbits. What about patient engagement with how medicine is practiced? On them. And their families. Paul Starr wrote his classic “Social Transformation etc.” a generation ago. Corporatized medicine didn’t happen quickly, it won’t be changed quickly. But it won’t change at all if we all throw up our hands and admit defeat. Atul Gawande wrote a graceful book about a painful subject. It’s a huge bestseller with the general public. Perhaps, a writer of his stature could humanize the topic of medical practice for general readers. The majority of… Read more »

Mighty Casey
Guest

“The people who are buying these systems, installing these systems, and determining how they’re to be used… What are they responsible for? What are their objectives? We’re having to figure out how to get quality and outcomes higher on the list of priorities of everybody running health systems.” That’s the crux of the issue confronting healthcare: patients aren’t even in the room, much less included in the process design, when system governance is under construction. This is a terrific read, and I found myself wanting to high five my screen while doing so. Yet and however, I’d suggest that both… Read more »

Chris Kapsa
Guest

Atul Gawande stands heads and shoulders above most others writing about health care. His fundamental decency and humanity shine, even in this swatch of interview. I’ve been fascinated to read many posts here and the resulting comments that never mention patient welfare or illness or care that’s of value to the patient, not the payor. Care of value to the patient is only discussed in contexts of stopping it. There seems to be a medical technocracy echo chamber. Gadgets, hospitalists, ACOs, EHRs, bundled payments, MD angst (nurses suffer angst, too, BTW), quantified selves, HIT, CIOs…the list goes on. While out… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“out in the wild patients feel lost under the care of indifferent hospitalists”

You could paint a barn in one swipe with a brush that broad.

Saurabh Jha
Guest
Saurabh Jha

“You could paint a barn in one swipe with a brush that broad.”

Lol!

We all have our favourite bug bears!

Chris Kapsa
Guest

Are you a patient with a favorite hospitalist? A doc in private practice whose patients come back thrilled with the care they’ve received in the hospital?

Or a hospitalist?

Or none of the above, so haven’t dealt with the species yet?

Saurabh Jha
Guest
Saurabh Jha

“Or a hospitalist?”

I will be whatever you wish to template your prejudices.

I will be the species you consider the lowliest!

You’re welcome!

Granpappy Yokum
Guest
Granpappy Yokum

“I will be the species you consider the lowliest!”

Not fair! You always get to be the lowest.

I want to be the lowest.

Mommy, tell Saurabh to let me be the lowest.

Chris Kapsa
Guest

Perhaps you’re the exception that tests the rule… Thousands of hospitalists work for hospitalist/intensivist management companies. They’ve become rent-a-docs. Two of these companies, Sound and Cogent, are controlled by Frenesius, a big German HC conglomerate. So the care of thousands of hospitalized American patients is being indirectly determined in German boardrooms. Gotta love globalization. Hospitalists have to toe the hospital management line. Avoid admits, force fast discharges and take large case loads. Hospitals have to make those hospitalist contracts pay. Further, hospitalists are working with those dysfunctional EHRs, so it’s difficult to learn much in depth about patients in any… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

I agree with about two-thirds of what you say, the two-thirds that also applies to out-patient docs who are employed by corporations. All of it is the result of a broken system, one that victimizes both patients and physicians. But you want to make it into a patient versus physician battle, which is just what Frenesius et al want: that keeps us out of their way as they roll on down to the bank. I know too many smart, compassionate physicians working as hospitalists to accept your characterization of them as uniformly indifferent. They’re stressed out, over-worked, and trying to… Read more »

Saurabh Jha
Guest
Saurabh Jha

“They’ve become rent-a-docs.”

On that, or in opposition to eventuality, we agree.

Thomas
Guest
Thomas

@ Chris Kapsa
You have misspelled the co. name. For the record and your surfing convenience, it is really http://fresenius.com/

Bob Wachter
Guest

Thanks. Of course. There’ll be others, including Chris Sinsky, who has done pioneering studies on the impact of IT on workflow and clinician satisfaction. Still looking through the group to determine the most interesting ones. But thanks for the heads up.

Chris Kapsa
Guest

You’re welcome.