ALiEM Book Club: The Digital Doctor – Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age
Medicine is becoming an even more information-intensive field as we continue to make new medical discoveries. This, among many other reasons, has prompted increasing efforts over the past couple of decades to develop computerized systems in healthcare. Through this lens, Dr. Robert Wachter examines modern medicine – both the achievements and downfalls that have manifested.
Dr. Robert Wachter is an internist, interim chairman of the Department of Medicine and chief of the Division of Hospital Medicine at UCSF [UCSF Profile]. Through The Digital Doctor [Amazon link], he offers a thorough look into the digitization of healthcare, as well as its impact on the patient experience, doctor-patient relationship, and clinical safety. Initiatives are expanding rapidly to enhance and develop technologies that will diagnose, treat, and reach new levels of clinical acumen to partner with (and perhaps eventually supplant) physicians.
Wachter expounds on several major themes that expose how health information technology has fallen short since our government’s $30 billion investment in electronic healthcare programs:
1. Doctor-patient relationships
Technology arguably interferes with the doctor-patient relationship. Doctors are making less eye contact and forming less emotional connections with patients as we have transitioned into the computer age of healthcare. Wachter quotes physician-author Abraham Verghese, “We’re losing a ritual that I believe is transformative, transcendent, and at the heart of the patient-physician relationship. The ritual of one individual coming to another and telling him things that she would not tell her preacher or rabbi; and then, incredibly, on top of that, disrobing and allowing touch” (pg 27). At the heart of medicine is human connection, compassionate care, and empathic interaction with individuals who are vulnerable and ill.
2. Medical Errors
The technology that is designed to reduce medical errors and increase patient safety may actually cause harm. Wachter centers this theme around a narrative in Part 3: The Overdose. A 16–year-old boy named Pablo Garcia with NEMO syndrome was given 38 ½ tablets of the antibiotic Septra before his surgery. He didn’t make it to the surgery; he suffered a grand mal seizure and nearly died from the 39-fold overdose. Wachter explores the origin of such a mistake at one of the best hospitals in the country. The drug information was entered into the computer system, which was then passed through several checkpoints (including the technician, pharmacist, robot, and nurse) before the medication finally made its way to the patient. The poor interface design of the EMR software played a part in the pediatric resident’s mistake of putting the dosage information in an incorrect unit setting. She had overridden the warning that the dosage was much too high, likely because most alerts she encountered previously were unnecessary. Ironically, the checkpoint process and computerized alerts were developed to avoid mishaps like this, but alert fatigue and a fallible check system are concomitant with a fairly nascent digitized healthcare system.
3. Deficit in Interoperability
One of the biggest issues facing the healthcare information technology field is the deficit in interoperability (connecting EHR systems used by different hospitals and clinics). Such an ease in communication would allow a smooth flow of patient information from one provider to another.
Wachter also broaches issues of big data (patient information databases), the productivity paradox (the idea that productivity has not increased but remained stagnant following the computerization of an industry) and, in a more positive light, he discusses the benefits of healthcare technology for the patient. In Chapter 20: OpenNotes, we learn about the history of patients gaining the right to view their medical records. Dr. Tom Delbanco, the founder of the Division of General Internal Medicine at Beth Israel Hospital, has been passionate about improving the doctor-patient relationship by advocating for the patient’s right to have access to his or her medical record. He created OpenNotes, a growing initiative to allow patients to view their doctor’s notes about their illness experience. Wachter quotes Delbanco, “Patients possess a body of knowledge about themselves that we can never hope to master, and we have a body of knowledge about medicine that they can never hope to master. Our job is to bring these two groups together so we can serve each other well” (pg 173).
The advances of technology may not ever reach a level of sophistication or clinical acumen that is sufficient enough to entirely replace a human physician. Among the many qualities that make a good doctor, there is one primary characteristic that a machine can never acquire: being able to emotionally connect and empathize with patients. Nonetheless, and despite the shortcomings we’ve discussed of healthcare information technology, we can be confident that great strides will be made to improve these drawbacks. Wachter, confident that we are moving in the right direction, expresses a deep optimism for the future as we continue to accommodate an increasing technological presence in clinical practice.
- Discuss the reasons why Pablo Garcia’s incorrect dosage information could have passed through several checkpoints but was still not corrected before reaching him. What are the ways in which this could have been avoided?
- Discuss some of the challenges that arise from patients having access to their medical records. What are the ways in which this improves the doctor-patient relationship? What are the ways in which it may harm it?
- Do you see us moving into an era where healthcare personnel will begin to share clinical spaces with technology with increasing harmony? What challenges might persist? Will there come a day when the computer will supplant the physician (or other healthcare professionals)?
* Disclaimer: We have no affiliations financial or otherwise with the authors, books, references, or hyperlinks listed. The Amazon links, however, are Amazon affiliate links.
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