Episode Transcript
Alan Helgeson:
Hello, and welcome to the “Reimagining Rural Health” podcast series, brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high quality, low cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.
Today’s topic is a conversation on health care’s digital revolution. Our guest is Dr. Robert Wachter, professor and chair of the Department of Medicine at the University of California, San Francisco. Dr. Wachter has authored 300 articles and six books, including the New York Times Science Bestseller, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.” In 2020 through 2022, his tweets on COVID-19 were viewed more than 400 million times by 260,000 followers, and served as a trusted source of information on the clinical, public health and policy issues surrounding the pandemic. Our host is Dr. Luis Garcia, president, Sanford Clinic.
Dr. Luis Garcia (host):
I don’t think that there’s any type of introduction that would really give the proper credit to what you have achieved. I think that we could spend three hours just in the introduction of this podcast to maybe get to what would be proper credit. First of all, our gratitude for being such an influential leader in health care, and what you have done benefits all of us, and your work has been so prolific that it has impacted all of us.
So, to that point, you know, I was watching a video the other day where you were interviewing Andy Slavitt. He used to be the administrator for CMS, and then he also is a senior advisor for COVID-19 for President Biden, and he described you as a health care citizen. And that’s a huge honor to be described that way. What are your thoughts about that, the nomination?
Dr. Robert Wachter (guest):
I like that. That’s very sweet. Yeah. I’ve always seen my career as being a combination of trying to be a really good physician and taking that part of my life very seriously, but also trying to make the system that we work in work better. And I think that’s the citizens part, citizenship part of it. You know, when I grew up in medicine, probably you too, the idea that the role of physicians, at least at the time, was you were gonna, you need to be a really good doctor. And what being a good doctor meant was being really good one-on-one with patients. If you did a technical thing as you do Luis, that’d be really good at having the skills to do it. And I was very lucky to have mentors who really taught me that. That’s all really important, but it’s also important to figure out how do you make the system work better?
And I, that came a little bit naturally to me because I was a political science major in college. I was someone who always thought about systems and people and organizations and money and structure and all that. And it’s been one of the great joys of my career to find out that even though I always felt I was a little bit of an oddball, having this interest in policy and politics and medicine, that actually there’s this Venn diagram and it’s really important that physicians are good at that. And so it feels – it’s sort of a nice thing to look back on my career and feel like I’ve made a contribution, both as taking care of individual patients, but also trying to make the system work better.
Dr. Luis Garcia (host):
Yeah. That’s very profound. And, and I know you joke often about being a political science (major) in college and then getting into medicine, and of course that surface in your tweets around the pandemic. But I read a statistic that is just so impressive that at the height of the pandemic, your social tweets were viewed over 400 million times.
Dr. Robert Wachter:
Yeah.
Dr. Luis Garcia (host):
How does it feel to have that kind of an audience?
Dr. Robert Wachter:
It feels like a fair amount of responsibility, and particularly during COVID. I mean, it was important to recognize, I’ve been on Twitter for about 10 years, and going into COVID, I had about 15,000 followers. And within a year, year and a half in COVID, I had 300,000. And that wasn’t because I got any smarter, more interesting (laugh) or from, you know, between 2019 and 2020. It was, I was choosing to weigh in on what was the most important issue of the in the world. And people were desperate for trusted sources. So when COVID hit, it struck me that I have this Twitter presence, and I like communicating that way. I also ran grand rounds at my, at UCSF, at my institution, and that was another platform. And I felt like one of my opportunities-slash-obligations is, can I use my voice and my platforms to help people navigate through this pandemic?
And there was a little bit of time where I had some imposter syndrome, as I often do as a generalist, because I’m sometimes weighing into areas where there are specialists who know a lot more about any part of it. But one of the things I’ve learned in my career is that there is a role for generalists and a role for specialists. And the system works best when you have partnerships between the two of them. And so that’s been true for me in patient safety, where I decided to get interested in patient safety, I realized I needed to find people who really understood cognitive psychology or how the aviation industry kept itself safe, or how nuclear power plant designers do their work. Same thing with when COVID hit, it struck me that there are going to be people who know everything you need to know, or you should know about virology or vaccinology or aerosol science.
But what I could do as a generalist is synthesize that to try to pull it together in a way that made sense to me, and then try to communicate it to others. So it was really very gratifying because it’s, it became very clear that there was an audience for that, both personal, regular people and professionals who said, this is the most important issue in the world. It’s confusing as can be. There’s new information coming out every five minutes. Some of it conflicts with what I thought I knew 10 minutes ago. Can I find somebody out there who’s pulling it all together and putting it out there in a way that I find accessible and interesting? So it felt like a lot of responsibility an obligation to get it right. And I guess the other thing I’d say about Twitter and social media in general is it’s an incredible soapbox.
You can reach a lot of people. There are a lot of crazy people out there who will say things that are just incredibly nasty. And you kind of have to decide whether it’s worth it, whether it’s worth it to be, you know, in that arena. I felt like it was. I felt like the value that I had and others who were doing similar things to communicating in communicating to people about what’s going on, what the new research means, in communicating a way that I hope would be trustworthy, where they would say, this is a person who seems to know what he’s talking about, is not too partisan, is not, you know, trafficking in conspiracy theories, is really using the literature, but also feeling comfortable that I would say to people, you know, my son has COVID and I’m really scared. Or, today I, my lunch, I remember I did this in April or May, 2020, I showed people a picture of my lunch. It was SpaghettiOs and double stuffed Oreos. And I said, this is just what I felt like eating today. (Laugh) You know, the world is so scary. So being comfortable not only tweeting out facts and analysis, but a little bit of your personal story, people seem to be looking for trusted sources that way. So it’s an, it’s a responsibility, but it actually was quite a gratifying number of years.
Dr. Luis Garcia (host):
So, you know, Bob, I love the willingness and the courage to be a public trusted source, and at the same time recognizing the responsibility that that meant for you at the time. Oftentimes, I discuss with our clinicians that COVID started as a clinical challenge. We had a new virus that we didn’t know how it was going to behave. We didn’t know the short and long-term impact of it. And we were trying to figure out every day what was the next step.
But very fast, it became a leadership challenge because you mentioned the different reactions that people had, whether it was politically driven or fear driven, it became a people challenge, a leadership challenge. Talk to me a little bit about how you navigated that as a leader in this nation.
Dr. Robert Wachter:
Well, I think somewhat holistically, I mean, one of the things that I’ve recognized in my career is that medicine is always partly political, partly ethical, partly sociological, partly economic. You know, you’re talking about a system that deeply affects people that is intensely personal. There’s probably nothing more, any more personal that is 18 or 19% of the gross domestic product is that is the major employer in many regions that is going to have to traffic in issues that are, have for many people religious overtones or deeply political overtones. And so, I don’t know how you completely can communicate effectively in medicine without at least appreciating all of the kind of sociological and political context.
And obviously in COVID, it became, those became particularly germane, partly because of the nature of COVID and the nature of public health, where there’s an immediate tension between experts saying things where people may be skeptical of the source of their expertise between authorities, whether they are institutional, like from a health system or governmental is telling people what they should be doing, in part because it’s an infectious disease.
So it’s not all about you as an individual, as it might be when we’re trying to figure out how to treat your blood pressure, your diabetes. In an infectious disease, what you do affects other people. And therefore there’s a communal interest in potentially saying to people, you know, I’m gonna restrict your freedom to walk around without a mask or to not get vaccinated, which of course is in the United States going invariably lead to some libertarian backlash, just the nature of our politic. It’s some ways, the core political question in America really, if you think about the parties, is what is the role of government? What is the role of central authorities? And good people on both sides have very passionate feelings about that. And it became very clear to me COVID was going to bring those out. So to me, I guess one of the things that I bring to the table and pretty unapologetically is taking a political lens and being comfortable with taking up having a political lens through which we see this.
One of the reasons I think that’s so important is, you know, I wrote a book about technology in health care six or seven years ago, and I think we’ve all been somewhat disappointed by how bumpy the road to digital Nirvana has been in health care. And the more I looked at that, the more I came to understand that we treated digitization in health care as a technical problem. We’re gonna put in these big things called electronic health records, and we’re gonna turn them on and they’re gonna make everything better. And it turns out everything is more complicated than that. Everything is socio-technical. Everything has an aspect of behavior and people’s willingness to follow guidelines and the relationship between people and their tools. So COVID brought those out to a greater degree than I think we’re used to.
But I think it is a failing in medical education that we often treat medicine as a technical enterprise where if we can just get the facts out and just tell people, take this vaccine or treat your diabetes, or get more exercise or drink more or drink less, or whatever, that we’re done. And I think we’ve come to recognize, no, we’re not, you know, the technical scientific knowledge is only the starting point of a much harder, and to me, actually more interesting challenge of, OK, that sounds, that’s important, but so is people’s attitudes, behaviors, the money, the politics, the policy. And I think COVID just brought that out in an incredibly interesting and obviously very challenging way.
Dr. Luis Garcia (host):
The book that you’re learning to was published in 2015. And I have it here in front of me, “The Digital Doctor.” And, and by the way, it’s a fascinating read. You talk in 2015 about many of the things that we’re dealing with right now as when, as it relates to the relationship of technology and physicians and patients. So, I mean, you are a visionary. You’re not only a leader, but you’re a visionary.
Dr. Robert Wachter:
You know what? Who is a visionary, I think is someone who has their eyes open (laugh) and asks good questions. And the only thing that was that if that book is visionary at all, it was my recognition that electronic health records were going in, health care was experiencing finally its digital moment. And when I looked around, all I saw was unhappiness. All I saw with doctors complaining about their electronic health records in ways that they did not complain about their iPhone or their, or their desktop computer that in many other, or, or complain about Netflix or complain about Amazon in other walks of life. It struck me that digital came in and yeah, there were a few bumpy years. I just noted yesterday, and Netflix just announced that they’ve mailed out their last red envelope after mailing out billions of red.
So, you know, that’s how they started before they became the Netflix we know today. So it’s not like on day one they figured it out. But in other industries, I saw digital come in, and really within a relatively short period of time, people said, this makes things better in this part of my life. And in health care, digital came in, and in many ways it made it worse. And in funny and unanticipated ways. So my epiphany was when I asked people, why is that the answers I got from doctors or tech executives were wildly unsatisfying? They made no sense to me at all. And I just said one day, particularly after we committed a really terrible error at UCSF, that could have only happened because of a digital system and it’s interfaced with people, I just said, I need to understand this better.
So that’s a long way of saying, I think what was visionary was my recognition that I didn’t understand why digital was so hard and why people were so unhappy with their digital tools and that I needed to, and ultimately found the time and energy to go out and just understand it better. And to do that, I had to talk to a hundred different people from every walk of life that I thought was relevant and try to synthesize it into a story. And that’s nice to hear. I haven’t gone back and read that for the last few years, but it’s nice to hear that some of it is held up pretty well. But it was only because I had the privilege of talking to a lot of very smart people who helped me understand why this path was so bumpy.
Dr. Luis Garcia (host):
One of the really smart people that you talked to is Dr. Relman. And Dr. Relman shares in your book, not his perspective as a physician, but his perspective as a patient. Yeah. Of how he fell. He had several fractures and he ended up in a very lengthy recovery. And he speaks about how it feels to be a patient in the era where we perhaps are being too concentrated on paying attention to a computer. So it’s not only about the physician, right? It’s about the patient.
Dr. Robert Wachter:
Yeah, of all of the unanticipated consequences that may be the most interesting and important one. The way I came to know that particular consequence, first of all, I remember reading an article that my friend Abraham Verghese who’s at Stanford wrote in the New England Journal around the time my book came out, maybe a little earlier, where he coined the term the iPatient. And he said, I won’t get the quote exactly right, but he basically said, the patient only exists to keep their digital medical record alive. You know, that they basically are a representative of the physical person. This person with their life and a family and all of the things that make us human is basically sitting in a bed as an avatar for what we are paying all of our attention to, which is the digital representation of the patient.
And of course, that only gets worse over time as we get more and more data and as we’ll talk about tomorrow as AI gets more sophisticated and better. And one of the seminal moments for me was the first article in the popular press about scribes. I don’t know if you use scribes at all here at Sanford, but
Dr. Luis Garcia (host):
We do. Yeah.
Dr. Robert Wachter:
We use a ton at UCSF. The first article that brought scribes to national attention was in the New York Times in about 2015 or ‘16. It was written by my wife who writes for the New York Times. And it happened because I came home one day and I said, Katie, you know how – and she’s covered technology for the Times for a decade before that – I said, Katie, you know how in every industry they computerize and immediately start laying off people? Only in health care could we figure out a way of computerizing, and now we’ve gotta add another person into the room so the doctor and the patient can look each other in the eye.
And she said, wow, that’s interesting. And so she wrote the first big article about scribes in the New York Times. Scribes are an epiphenomenon. Scribes are a manifestation of, OK, you take the patient’s data and you put it in this computer system and you create pretty clunky computer systems where even the process of just doing a regular search is not that easy and you markedly increase the documentation requirements for the doctor. People always blame that on the electronic health record. It’s not really the EHR’s fault. The EHR became an enabler for Medicare to ask you to document these things. For, to, for billing or for someone measuring quality for all I know you are asking people to document certain things because that’s associated with higher quality medicine or demonstrates how sick the patient is. But the consequences of that is the doctor who’s sitting there who you want to have, be making eye contact with the patient is now spending mu much of his or her time looking down at the computer screen.
And the patient notices that very quickly and says, it looks like the doctor’s actually not paying attention to me. What’s happened here? And so what’s the cure for that? Interestingly enough, this cure will probably be better technology. The cure will be digital scribes, will be that you and the systems now are getting good enough that they’re pretty much ready for prime time. That you’ll be having a conversation with the patient. You’ll be able to make eye contact with the patient. That conversation will not only be transcribed, which is easy to do, but that doesn’t help but turned into a doctor’s note. And as the AI gets better, you can actually turn it into a doctor’s note and say, make it in the form of a surgeon’s note, which might be different from an internist’s note. You can even say, make it in the form of Bob Wachter’s notes.
And it can go and look back and look at my last 3,000 notes and put it in that form. Which is, so the technology in some ways creates the problems. And then ultimately, we have to have the technology bail us out. But while we do that, we also have to take a step back and ask some fundamental questions. If the patient is perceiving that I’m not paying attention to them because I’m busy paying attention to this computer screen, that is immediately going to lose trust. And when we lose trust, we’ve lost everything. But the patient doesn’t trust that you’re there because you care about them deeply and you’re listening to them with all of your energy. You, we’re all screwed. I mean, it really is very hard to have the right kind of doctor-patient encounter that we need. So that was just one of many unanticipated consequences that I saw that had nothing to do really with the quality of the digital interface, with the quality of the computer.
They all had to do with what happens when you change the nature of the work, digitize it. None of it’s anticipated.
Another one I went into in the book, which a lot of people have commented on, is in the old days, geezers like me, went down to radiology every day to look at their films. When I talk to the residents now and I tell them that story, they say, what’s a film? (Laugh) They’ve never seen a film. What’s a view box? There was a view box. They have no idea what I’m even talking about. So periodically when I’m on the wards, I’ll say to my team, let’s go down to radiology. And they’ll look at me like I have three heads. Like, why do we need to do that? Don’t you know you can see the image on the computer? I say, yes. Don’t you know you can read the radiologist’s report? I say yes.
And then I take them down and they’re invariably awed because you go down there and the radiologists now welcome us down there, in part cuz they recognize that if they don’t, the younger people will never go down there. And you have this absolutely wonderful, really important conversation, give and take between the front-line doc and the radiologist and the radiologist reports said so and so and so and so. But then you say to them, well let me give you a little bit of clinical context. This is the story. Oh, the radiologist says, well then I would really worry about this and this. So in that exchange, you’re providing better patient care. You’re getting smarter cuz you’re learning from the radiologist. The radiologist is getting smarter cuz they’re learning from you. I’ve gone back and spoken to the people that were at the leading edge of digital radiology and asked them, did they have any clue, any inkling that digital radiology would change the nature of the front-line clinician-radiologist interface?
And none of them said it even crossed their mind. And of course, in retrospect it’s obvious, why did we go to radiology every day? Why did we have radiology rounds? It’s designated time for radiology rounds every day because it was only one place where you could see the film. It lived in only one place and it was in the radiology department. Once it became digital, you no longer had that forcing function. And the same thing is true when I go to the wards. I’ll go to the wards and there are nurses all over the place. There are no doctors cuz the doctors went and see the, saw the patient, and then they went off into their room, their digital room often where they’re hanging out with each other to do their charting. In the old days, you spent your entire day on the floor because there was only one physical copy of the chart. There was only one place where the lab test came to.
So that’s just, those are examples of these unanticipated consequences that happen that are really not about the technology itself. They are the kind of sociological community relationship things that were built around the lack of technology. And we’re just not smart enough and creative enough to understand what’s gonna happen when the technology comes in until we see it. And it’s like, hmm. And then if you don’t have geezers like me around anymore, the young people never knew there was such a thing as radiology rounds. So they don’t miss it.
Dr. Luis Garcia (host):
It’s just amazing to see that despite the tools and technology and what are advancements we have, it really comes down to basic human interactions. Right? You cannot take away the value of that. And whether you call yourself a geezer leader or whatever title you wanna give yourself, I gotta tell you, I’m gonna call you a mentor because that to me is mentorship.
Dr. Robert Wachter:
Thank you.
Dr. Luis Garcia (host):
And I’d like to ask you a question. Nobody gets to the caliber of who you are by randomness or you know, by luck. Had a lot of work, a lot of mentorship. Do you recognize one mentor in your life that you go like, yep, that person changed my life because of whatever?
Dr. Robert Wachter:
Probably the most influential mentor I’ve had is a guy named Lee Goldman who was chair of medicine at UCSF in the mid-‘90s to the early 2000s, ultimately became the dean at the School of Medicine at Columbia. Lee’s this – and so it’s always shocking to me when I’m now the chair of medicine at UCSF. So the fact that I have that job when I think about how incredibly smart and strategic he is, so I have a little bit of imposter syndrome every day. But when Lee came, Lee had been a resident at our institution, went off and spent most of his career at Harvard and then came back to be chair of medicine. And he asked me to take on this new job. I had been residency director at the time.
He said, I want you to be my right-hand person running clinical work. And I said, I love running the residency. And he said, yeah, but basically stick with me. We’re gonna do big things. I want you to be my person and your level of growth in that job will be greater than what you would’ve experienced in the residency. And I, that turned out to be right. The things I learned from Lee, one is he hated the status quo. He just said, and that’s how the hospitalist field happened. So Lee and I wrote the first article that coined the term hospitalist together. And that happened because Lee said to me, you’re in charge of the inpatient medical service. I look at the medical service and it looks exactly the same as it did when I was a resident here 20 years ago. That can’t be right.
So the instinct that he had when a system that had not changed in a decade had to now be wrong because the forces of status quo and inertia are so strong, and I’m lazier than that, it was like, that’s not, would not have been my instinct. It is now when I see a system that hasn’t changed, whether it’s the way we pay people or the way we organize something, my instinct is always that can’t be right. How do we make that better? And that’s where the hospitalist thing came from. We sort of thought about how do you change inpatient medicine? Came up with this concept that actually it probably needs a separate specialist, but not a subspecialist. Someone who’s a generalist who is in charge of this general hospital care but lives there all the time. And the model for that was really what had happened in emergency medicine and what had happened in critical care medicine 30 years earlier.
So that’s kind of how the whole hospitalists field happened. But the one moment that encapsulated Lee to me, and I think I’ve tried very hard to pay this forward, is a very early meeting I had in his office. He invited me in, I’m sitting on his couch, he’s behind the desk, he’s on the phone, he’s editing the Cecil textbook, the big textbook of medicine. He’s the editor, he’s editing it while he is on the phone while having this meeting. He’s one of these remarkable multitasking people. And it was clear he was having a meeting about some leadership thing on the phone. He had the person on speaker so I could hear, and it had something to do with money and space and parking and the usual stuff. And he says to the person, Joe, can I put you on hold for a second?
And he puts the person on hold and he turns to me and he said, this person wants this and this and this. This other person wants this and this and this. Here’s the big picture, like what we’re trying to do as a department. He said, what would you do? And I said, my God, he’s pimping me on leadership the way, you know, in the old days we used to do about clinical medicine presenting a tough case. What would you do? And he is investing in, he believes in me as a potential leader and is going to basically teach me how to do this and is gonna challenge me. So I babbled something about what I would do. And he said, not exactly (laugh). And then he put the person back on speaker and told me what he did. And I said, this is a good decision to work with this guy because he takes one of the things that he wants to do. I now recognize what he was doing was succession planning. Really what he, what he recognized in me, something I didn’t recognize in myself was that I had some leadership potential and that he was going to mentor me and that I was gonna be watching everything he did. And periodically he was going to stop and ask me a question or stop and contextualize what he was doing. So I would learn that. And so a huge amount of what I think I do in leadership, I’ve learned from him.
Dr. Luis Garcia (host):
I agree with you that teachers see on us things that at times, oftentimes, we don’t see on ourselves. And a good teacher mentor is one that allows you to exploit that in a productive way. So, I love that story. I think that you describe also a situation in your life where you found a fork on the road and you had to make a decision of this or that you had a promising career going to the right, but perhaps a promising career going to the left or vice versa. And you chose – so talk to me about risk in your life and other times in which you went like, oh, what would I do? And what helps you make those decisions?
Dr. Robert Wachter:
Yeah, I, the one that comes to mind the most, and I tell young faculty this at our place, there are very few successful, whether it’s faculty members or people who’ve had other career paths, but very few. I find that when you say to them, you know, was it completely linear that from the time you were in diapers to where you are now, you had this view of what you were gonna do and everything just happened at lockstep and you got the right skills and the right qualifications? There’s almost no one who tells that story. The story is always a bump in the road. Something went wrong or an opportunity arose that they couldn’t have anticipated. And a lot of it is, you know, have you positioned yourself to be open to that? Are you asking questions? Are you taking in, are you sort of looking for new knowledge, new people, new relationships?
Because a lot of it is shots on goal. A lot of it is, you know, creating enough opportunities for those things to happen and then recognizing them when they happen. I think my interaction with Lee was one of them. When Lee asked me to take on this different job than the one I had, and I loved the one I had, but he convincing me and ultimately the making the right call that changing jobs to work with him in a larger leadership or a different leadership role was a good call. Probably the biggest one for me was I finished my residency in chief residency. I did a fellowship that was largely focused on research, epidemiology, outcomes policy at Stanford. And then I came and joined the faculty at UCSF and I got the job you’re supposed to want to have in academia, which is quote “protected time,” meaning I had about 70 or 80% of my time was funded by the system for me to do research with an expectation that in two or three years I’m gonna bring in enough grants to pay for that portion of my time.
So I was about 20 or 25% clinician, about 75% researcher. And I had written a number of papers up to that point. And I, people saw me as having a lot of research potential. I put together a big multicenter grant for what I was working on at the time, which was how AIDS patients did when they went to the ICU. Just to show you how long ago that was. You know, there were almost no AIDS patients that go to the ICU anymore. But back then there were. There were a ton. I spent a lot of time on this grant, put it out there, sent it off to the funder and got turned down. You know, it wasn’t even close. And I looked at it and there was a little bit of thumb sucking about, you know, oh, you know, it hurts to get rejected.
But for me it was a moment of introspection, which is, do I want this as a career? Do I want my incentive to be, I’m always trying to publish the next paper? Write the next grant? To me, I recognize that I did. I thought I’d maybe be successful at it, but I didn’t think I’d be that happy. I didn’t think I had the fire in the belly to be that person. And I have hundreds of people like that who now work for me. I admire them deeply. I think it’s an amazing thing that they do. And they’re incredibly impressive. I just think I’d be great at it. And I didn’t. And I thought I was too social. Cuz I think the incentive in that system is you’ve really gotta close the door and write the next grant. And I like talking to people and learning things more than that.
And so decided that that was not gonna be my career path. And I actually did not know what my career path was going to be because I liked being in academia. So it was like, all right, I don’t think I wanna be a full-time a hundred percent clinician. I’m not gonna be a researcher who’s 70 or 80% research and research funded. What do I do? And it was sort of through that period of reflection that I said, I kind of like leadership. I never saw myself as a leader. I wasn’t the president of my high school class. I always thought I was a little bit too goofy. But I was lucky enough to become a leader at an age where people, goofiness became authenticity, (laugh) that the characteristic of someone who’s reasonably accessible is a good listener, became leadership skills that were, became increasingly valued from an, in a prior era where the leader had the most gravitas was really scary, was someone who was very hierarchical.
The idea of a leader being someone who might be accessible, be someone who, you know, people can call by their first name was, became acceptable. And it was like, oh, OK, maybe I can be decent at that. And then it became one leadership role after another and became something that I over time recognized that I liked, was good at and gave me a platform. Even though I didn’t want to be a full-time researcher, I liked writing, I liked thinking, I liked being a thought leader. And through my leadership roles, I recognized that not only could I carve out enough time to do some of that writing and leadership work, but also it gave me an altitude in my health care organization where I would be seeing things that would give me insights into technology or insights into patient safety or insights into how we organize hospital care that I wouldn’t have had if I didn’t have a leadership perch. So it all, you know, I mean, I can describe it now and it sounds like it all was planned and intentional. It mostly was happenstance and just getting into the right place, the right time.
Dr. Luis Garcia (host):
But I love that story, Bob, because I think that by nature we always incentivize our younger generations to look at their strengths, right? But I don’t think we pay attention enough to what, recognizing what your weaknesses are and not engage in a journey where your weaknesses were surfaced, you know. So I, and I think you perfectly describe an instance where you identified, this is not for me, this is not where my strengths are, so I need to pivot and do something different. And, I think that’s the – you talk about the holistic human being and recognizing where you’re good at. What are you not good at? And how do you allow that to drive into your life? So let me ask you a question. Have you ever made a mistake? Have you ever disappointed somebody?
Dr. Robert Wachter:
(Laugh) I had a failed first marriage. So I, I’d say that would be the biggest mistake I’ve made in my life and didn’t seem that way at the time, obviously. But that was hard cuz I’d been successful in most of the things that I had done and professionally successful. And, you know, arguably your marriage becomes, is one of the most important decisions you make in your life. And I remember holding onto the marriage for a number of additional years cuz my kids were in high school, and I kind of had decided that my ex-wife and I almost collaboratively decided we would stay together until they finished high school. I remember talking to an old college friend one day and struggling with this in part because I really felt like it was a failure and I wasn’t used to failing in many things.
And I said, you know, partly we’re staying together for the kids. And he said, the most important lesson you can give your kids is there’s no problem that’s so bad that you can’t figure out a way of making it better. I thought that was really profoundly important. And it turns out that we ended up splitting and it was amicable and been married now for the last 15 years to the most spectacular person in the universe and we’re incredibly happy. And, but that, as I think about mistakes I’ve made, that’s probably the biggest one. But I think it also taught me some incredibly important lessons.
Dr. Luis Garcia (host):
And how do you rebound from, from when you hit bottom right? And I – to the point that you dedicated this last book to your current wife Katie.
Dr. Robert Wachter:
Well, partly because she’s wonderful and partly because I came home the day I decided to write the book was this day, I was chairing our patient safety committee and we gave a kid 40 Septra tablets. Forty. Forty antibiotic pills when the correct dose was one. It was just a breathtaking error. And it only happened because of digital systems interacting with humans, but all the usual stories of alerts firing, but people ignoring them because they got a hundred alerts a day that were all false positives and several other things. I came home at the end of the day and I said, Katie, I think I need to wanna write a book about this. I said, you know, we’re at this incredible moment of digital transformation. I thought it was gonna be so great and it’s not great. And she said she said, I think that’s a great idea.
You should write a book about it, but you need to do it journalistically. As I said, she’s been a journalist for 40 years. She’s quite good. She says, you have to do it journalistically. And I said, what does that mean? And she said, it means you’re gonna have to go out and talk to people. And I said, I hate people. And she said (laugh) she said, you know, I was joking. She said you know, you’re actually gonna love doing this. I’d never done anything like it. And so I took a year partly on sabbatical and interviewed everybody I could think of who had any insights. So everything from the CEO of Epic to cognitive psychologists to interviewing Captain Sullenberger, the pilot who landed on the Hudson, who said, you have to go to Boeing to see, to talk to the cockpit engineers there.
Next thing I know, I’m on a flight to Seattle and I’m flying a triple 77 simulator in Boeing headquarters. So one of the most interesting, rich experiences, but it was really only through Katie sort of seeing that the only way to get this story right was to go out and learn everything I could about it from a lot of different vantage points. So dedicating it to her was partly that, and partly we have, one of the metrics of a marriage is we actually are one of the few couples I know who can edit each other and not kill each other (laugh), which is a hard thing to do, but she’s a wonderful writer and I’ve learned a lot from her.
Dr. Luis Garcia (host):
Well, thanks for sharing that story. I didn’t know that what prompted you to write that book was that medical error with a child.
Dr. Robert Wachter:
Absolutely. When it happened, I went to the head of risk management and I said, this story is so rich, there’s so much in it that are general lessons about digital human interfaces that I think we have to disseminate this. And I said that to the head of risk management and she said, oh, that’s a great idea. Let’s have some, you know, let’s do grand rounds. And I said, well, I’m actually talking about writing a book about it. And I think her hair went on fire (laugh).
It’s like, what? You’re a risk manager. It’s like, this is not a great idea.
Dr. Luis Garcia (host):
You’re gonna make public what? (laugh)
Dr. Robert Wachter:
Ultimately the CEO of our health system, I felt it was important enough for him to, that he needed to greenlight it. And he thought about it for about a week and then then said, you know, one day he said, you know, this story’s so important that I want you to write about it. So I thought that was really a brave and courageous thing to do, but I think the right decision.
Dr. Luis Garcia (host):
I agree. And it was the right decision on, on his behalf as well. And so somebody would argue that you have done so much and you have reached levels that not every human reaches. Do you think you have reached your potential? What’s next for Bob Wachter?
Dr. Robert Wachter:
I’m really proud of the things that I have done, and I’m never good at saying what’s next. Because when I look back at my career, what I see is a thread of leadership roles that have felt important and interesting where I felt like I could make a difference pretty much all at UCSF. So in a big academic institution and one I like very much and respect and like the culture, and like living in San Francisco, but my career has been a succession of every five to seven years. An issue that seems really interesting to me, that fits into my sweet spot, it’s gotta be pretty clinical. It’s got, it can’t be insurance policy, it has to feel very close to the ground. So very clinical often has a training aspect to it, but all has money, policy, politics, ethics, sort of rich sociologically complicated.
And that has led me to studying the politics of AIDS and activism to studying the organization of hospital care, to studying patient safety, to studying the digital transformation of medicine to studying COVID. COVID is drying up now, thankfully. So I suspect I have one or two more of these in me, but I’m never good at predicting them. And it’s not like I say, all right, it’s seven years, it’s time for me to do the next thing. It usually is at seven years or so, the last thing is feeling a tiny bit stale and I’ve kind of done what I can do, and a new thing emerges. And I just say, that is so unbelievably interesting and I think the way I think about the world, maybe I can make a contribution. So it sort of feels like AI is sort of the next step of the technology thing I’ve been paying attention to. It feels like the new advances in AI are that, but what that means in terms of, I don’t know, writing a book or just being an interested observer, I’m not sure. We’ll have to see.
Dr. Luis Garcia (host):
Well, I can’t wait for the next five to seven years cycle. And I definitely wish that for you, it’s not two or three more, but many more seven year cycles because your contributions have been just phenomenal. Bob, this has been a pleasure, an honor for me to sit here and share some thoughts. Any closing thoughts that you want to share with the new generations, with the new leaders?
Dr. Robert Wachter:
I’ll tell you a quick story to end this. At my institution several years ago, we were talking about all the changes in medicine, technology, payment change, regulatory change, everything else. And one of the very senior, highly respected clinical cardiologists got up at the end of this meeting. He usually didn’t speak much at these meetings and he said something I’ll never forget. He said, you know, this could be worse. And I was very surprised cause he was definitely old school. I was very surprised. But then he went on and he said, I could be younger. And I like that story. First of all, I found it very amusing, but I actually think he’s wrong. I actually think that the world we’re entering in health care is one in which the capacity to take care of patients in a way that is better and higher quality and safer and more satisfying, more equitable and less expensive.
I think we haven’t done very well in any of those regards. I think we have the capacity to do that in part through digital systems. But digital systems married with people who never forget about the human aspects to it. So I think it’s gonna be up to great systems and you happen to be in one of the great systems in the United States to think about how we leverage the technology to make care better, safer, cheaper. And I don’t think he’s right. I don’t think medicine has had its golden age. I think we will over the next 10 or 20 years, and I look forward to doing what I can to help. But I think I’m a little bit jealous of, you know, my daughter is an intern in medicine now, so I’m a little jealous of people of that generation cuz I think they’re gonna see some spectacular changes that are gonna be for the better.
Dr. Luis Garcia (host):
Well Bob, thank you for those closing thoughts. And I agree with you. I think that the next two decades in medicine are gonna be positive and energizing. And, and I don’t think we have reached our maximum potential. So thank you, Bob. Whether somebody sees you as a mentor or as a teacher, or as a leader, or as a clinician or as a generalist or as somebody that coined the term hospitalist, it doesn’t matter to me. You are the definition of a great human being, and it is an honor to spend some time with you today. And to our listeners, I wish you could be here to shake Bob’s hands because he’s just a phenomenal leader and influential person in our health care. So Bob, thank you very much for spending time with us.
Dr. Robert Wachter:
Thank you, Luis. It’s really been my honor and it’s just a great pleasure to visit you and get to know your system better.
Alan Helgeson:
You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org, or Sanford Health News. I’m Alan Helgeson, and thank you for listening.
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Posted In Leadership in Health Care, News, Physicians and APPs, Virtual Care
