Here is the full transcript of Dr. Victoria Sweet on Slow Medicine: The Way to Healing @ Talks at Google conference
REBECCA MOORE: Good afternoon. Welcome to Talks at Google.
My name is Rebecca Moore. I’m Director of Google Earth. And I’m very pleased to welcome my dear friend, Dr Victoria Sweet, who just published a new book called, “Slow Medicine, the Way to Healing“. I’ve known Victoria for several decades, since nearly the start of her journey as a physician, including her 20 years practicing at Laguna Honda Hospital in San Francisco and taking time to get her PhD in the history of medicine.
During this period, she’s been on the front lines of dramatic change in her profession, as practicing medicine has transformed into delivering health care, and not always for the better. Her first book, “God’s Hotel,” won widespread awards and acclaim, leading to a Guggenheim Fellowship. And the time — pay attention to that word because you will hear it today a lot — the time for her to synthesize and develop her ideas further, around what she calls slow medicine and fast medicine and how these two approaches are both complementary and necessary. Googlers will particularly appreciate that. Victoria got her undergraduate degree in mathematics from Stanford. Go Stanford.
So please join me in welcoming Dr Victoria Sweet.
VICTORIA SWEET: Thank you. Thank you very much, Rebecca, for that introduction. Thank you all for being here today. And thanks to Google for doing something this — really unusual for a big for-profit company to be willing to sponsor books and speeches by authors. It’s a really wonderful thing, and special I think. It tells a lot about Google.
I would like to add that not only did I get my mathematics degree at Stanford, it was my major. But my minor was classics. And that is a stream, as two things have woven their way through my life. So what I would like to do this afternoon — I’ll speak for about 40 minutes. And I’ll be explaining kind of how I actually got right here. That’s the first part of the talk.
And the second part of the talk, I want to talk about what’s gone on with medicine during my career and what I think we can do to make it better. So I’m going to start with my – yes. So the first thing you should know about me is that I don’t consider myself a natural-born doctor. And by that I mean growing up I never watched doctor shows or went to volunteer in a hospital. And if somebody was sick, I didn’t want to hear about it or have anything to do with it.
And, in fact, the first time I had to draw blood in medical school, I passed out. So definitely not a natural-born doctor. What happened was at the end of college, I was looking for a way to synthesize these two parts of myself, the mathematics, the classics, the history, the humanities, and the sciences. And I ran into the writings of Carl Jung, the psychiatrist. He’d written a memoir called “Memories, Dreams and Reflections.” And I ran into it by accident in the library.
And I found myself enthralled. I was enthralled, first of all, by the meaning he expected from his own life and also by the kind of life he set up for himself. This is a stone house he had built himself on Lake Zurich. And this is where he saw patients in the morning, neurotic, well-paying patients in the morning, and illuminated manuscripts and studied alchemy in the afternoon. I thought this was a great life. And that’s what I wanted to do when I grew up.
And that’s how I got to medical school because I was going to be a union psychiatrist. Then it turned out I liked medical school a lot more than I thought I would, especially the last two years of medical school, when you finally get a chance to see real patients. I loved what’s called the work-up. I loved the history, taking the history, trying to figure out the patient’s story because there was so much psychology to it.
Hearing what the patient said and didn’t say, seeing what — the way he said or she said, the answer to the question. And then I was examining the patient. And it turns out I actually liked touching people. I particularly liked the physical exam because there was so much I could learn from that about what the patient had and didn’t have. And then there was putting it all together in a diagnosis, and the treatment, and the plan. It was a logical, brilliant method.
Nevertheless, I continued my first idea. And I went into a psychiatric residency. And I was a little bit naïve. So my psychiatric residency took place in the only locked psychiatric ward in our county. So consequently, the patients were not Jung’s well-paying, neurotic, articulate patients. They were severely psychotic. And they responded a lot more to the, um, medicines we used than they did to the talk therapy I tried. So after I got my license, after that first year of internship, I just went out and practiced medicine for several years in various clinics. And it was fascinating.
Because the county clinics and the community clinics would get waves of immigrants every time there was a war or a rumor of war. And they would bring with them their diseases and also their different way of looking at the body. I saw everything in those clinics. I saw three cases of leprosy. And this is right around here, when I did this. I saw most every parasite there was and saw many unusual diseases.
And I was also interested in these different ways of looking at the body. And so after a while, I decided that I might as well admit that I liked medicine. I went back and did three years of a regular medical residency. And then I went back to the community clinics.
And the longer I practiced medicine, the more impressed I was by the logical method of writing out a diagnosis and a treatment. But I was also more and more impressed by what this medicine, modern medicine, left out, which was, of course, anything that wasn’t logical.
So after a while, I started reading alternative medicines, naturopathy, homeopathy, Chinese medicine, and Ayurvedic medicine. And for a while, I even thought about learning Chinese, so I could understand Chinese medicine from the inside; or Sanskrit, so I could understand Indian medicine from the inside. But eventually, I decided that even if I did get to that point, that I could understand them, their cultures were still too different from my own to understand their different ways of looking at the body.
It was this rather discouraging moment that I discovered the writings of a very unusual 12th century woman. Her name was Hildegard of Bingen. And she was a mystic. She was a composer. She was an artist. She was a theologian. But she also, as it turned out, was a medical practitioner. And she’d written a book on her medicine. And as I stood there and read her book, in the library again, I was impressed by the medicine that she was recounting. Because it wasn’t the medieval medicine I’d expected, the tongue of newt, eye of frog medicine I expected from a medieval medical text. It was real medicine, for real patients, with real diseases I could recognize.
But it was based on a completely different model of the body from our modern medical model. I couldn’t quite put my finger on how it was different. But I decided then and there that I was going to go back to school and get a PhD in medical history, with Hildegard as my focus. But I didn’t want to stop practicing medicine.
I wanted to do this half-time. And I spent a couple of months looking around for a half-time position, which was rather difficult at the time. Until finally I discovered — I was offered a position at a very unusual hospital in San Francisco, which was called Laguna Honda Hospital, in San Francisco. And when I drove over for the first time and saw it high on that hill, I was taken aback. This was about 20 years ago now.
It looked like a medieval monastery. It had red-tiled roofs, and cream-colored walls, and a turret, and a bell tower, where patients, it turned out, used to go up and smoke. And I went on my interview. And the medical director took me around. I had never seen a hospital like this. It was on 62 acres of land in the middle of San Francisco. It had 1,200 patients. It had enormous grounds. The patients all got taken care of on these old-fashioned wards, those open wards you see in the old movies from the 1930s. It had an X-ray department where we could take our own X-rays and a lab with a microscope where we could look at our own slides.
It had a chapel, a little small chapel, that was run by the county. It had a chapel that actually looked more like a church, with stained glass windows, and polished wooden pews, and very politically incorrect stations of the cross along the walls. And then we went out. And the medical director showed me the grounds, which were enormous. There was an aviary, so that patients could watch chickens hatch from eggs.
There was a green house, so that patients could pop plants. And there was even a barnyard, so the patients could see animals, even if they were bed-bound. Then we walked back to her office and she offered me the job. Well, I didn’t know I wasn’t sure. I had never seen a place like that before in my life. But it was only place that would let me practice medicine part-time. So I said I would stay for two months. And I ended up staying for 20 years. Because it turned out to be a fascinating place to practice.
And that was for one specific reason. It had originally been called the San Francisco Almshouse. This was the first rendition of Laguna Honda in the 1860s. And the almshouse was actually how we used to take care of the sick poor before there was health insurance. We had a way of taking care of the sick poor. And that was this system that was the big, old county hospital, where anybody could show up and get taken care of.
And then if they needed more care than that, we had someplace to send them. So this is where, in the old days, we could send people who were mentally ill, who needed more care, who were unemployed, who’d just been let out of prison. We actually had a system. And Laguna Honda was the San Francisco Almshouse. And it’s how I got the title for my last book because this is — the system that we have, came from France, and Europe in general. And in French, the word for almshouse is hotel-dieu. It’s God’s hotel. So that’s how I got the name. And the reason I ended up staying so long is because typically the almshouse would get the bottom 1/10 of 1% of patients.
So my patients were all three standard deviations from the mean, any mean. They were the tallest and they were the shortest. They were the fattest and they were the thinnest. They were the oldest, and the youngest, and the nicest, and the meanest of any patients I ever had. And, because the whole catchment area was San Francisco at the time, with 600,000 people, if a disease would occur in one in a hundred thousand, I’d see a couple.
So it was a fascinating place medically. I just went through the rare diseases in Harrison’s textbook of medicine and checked them off as they would come up. So it was a fascinating place to practice. And I ended up staying for 20 years. But it also a wonderful place to practice because health care efficiency had not yet arrived.
We were over the hill to the poorhouse literally. And people kind of left us alone. I mean, we had standards and things. People paid attention to what we did. But mostly, I had something that doctors today mostly don’t have. And that is the time to take care of my patients, to properly examine them, to figure out what was actually wrong with them, to get the right diagnosis and the right treatment.
And the longer I was there, the more impressed I was by not only how, um — how satisfying that was for me as a doc, but how efficient it was, even from a health care efficiency point of view. And I’ll give you an example. The typical patient at Laguna Honda would arrive on between 15 and 26 medications, of which they only needed about four or five. But no other doctor had had the time to go through the chart, go through the patient, figure out whether they actually needed that medicine, maybe even try taking them off that medication to see how they did.
I found that most of the patients could be handled very well on five medications. So I was taking them off between 10 and 15 medications, which, if you figure it out economically, is incredibly cost effective for the extra few hours of time it took me. So I was quite happy there.
And then meanwhile — of course, I’d gone back to study — so this is actually what I call the efficiency of inefficiency. Meanwhile, I’d gone back, as I had decided to do, to get my PhD in medical history with Hildegard of Bingen as my focus. And what I decided to do was to really learn Hildegard’s medicine as if I were its student, by reading her medical text in its original language and by understanding what people were doing around her.
So I took classes and learned Latin because she wrote in Latin. And I learned medieval Latin because she wrote actually in medieval Latin. I learned medieval German and German because that’s what the secondary literature was in. And learned paleography and codicology, so I could actually read the handwritten texts which they had back then.
And I also experimented. Because I figured if I’d been her student in the Middle Ages, I’d sort of have a sense of using her different recipes and prescriptions. So I planted a medieval herb garden. And I brewed up some of her potions and syrups. I tried her medicinal beers. And I baked some of her anti-depressant cookies. And what I found over time, I got more and more interested in the difference between Hildegard’s model of the body and our model of the body because they were clearly very different.
Our model of the body is fundamentally based on the idea that the body is a machine and the doctor is a mechanic, looking for what’s broken and trying to fix it, repair it, or replace it. Hildegard’s model was very different, I gradually learned over the years Hildegard’s model was much more of the body as a plant, rather than as a machine, and the doctor more like a gardener, than a mechanic.
What’s the difference? The difference is that someone has to fix a broken machine. But a plant can heal itself. And Hildegard had a name for the power of a plant to heal itself. She called it “viriditas,” from the Latin “viridis,” that means green. So it was the greening power of a plant to grow, to produce seeds, and to repair itself up when it was injured. And she believed that human beings also have this power. And that the job of the doctor was more to remove what was in the way of the patient’s viriditas and to support it with the basics, than to do something to the patient. So this was a very interesting model.
And it took me years to understand how to apply it to the patients I had at Laguna Honda. But gradually, I began to see that not only could I help a patient by figuring out what diagnosis they actually had, but once I had the diagnosis, to step back and see what was in the way of viriditas and what could I do to support it.
The longer I practiced medicine at Laguna Honda, the more I realized that this was a very helpful way of looking at patients. And I began to think of it as sort of the slow medicine, as opposed to the fast medicine I also used, which was so effective for what I consider fast diseases.
So, for instance, if you come to the hospital because you have appendicitis and you need an appendectomy, or you come to the hospital, and you are having a heart attack and you need an angioplasty, or even if you have cancer, this is when, what I would call by contrast, fast medicine or modern medicine, based on the model of the body as a machine, works great.
But after your appendectomy, and after your angioplasty, and after your chemotherapy, this is when modern medicine, with this idea of coming in, fixing what’s broken, falls down. And what I learned at Laguna Honda is, when I used both models together, first fast and then slow medicine, the patients did the best. They did remarkably well. Many of them were actually able to go home, sort of unexpectedly.
And during the 20 years I practiced medicine, while I was practicing medicine at Laguna Honda, we eventually got discovered and our halcyon days of having enough time began to disappear. And, first by health care efficiency experts, who showed up one day, walking through the place and horrified to discover the aviary, and the greenhouse, and particularly the open wards. And the Department of Justice finally, eventually, showed up and told Laguna Honda that they were going to have to tear the place down and rebuild a new health care facility, that had private rooms for all of the patients, rather than keep the patients on the open wards.
And at that point, I decided to take some time off and write a book about what I’d seen there. That was my first book. And also to think about what I had seen so far in my life as a physician. It seemed to me, when I thought about, that in my life as a physician, the pendulum of health care had swung from the personal to the efficient. And I have been more and more impressed by what that leaves out.
So, for instance, the results of the kind of health care efficiency we’ve had over the last 20 years, as you can see, is that health care costs have kept rising no matter what health care economists have tried to do. They’ve tried to do all kinds of schemes for getting a hold of health care. And this is not true just in the United States, but across the world. Health care costs keep rising every year, despite DRGs and HMOs, and managed health care systems, everything we’ve tried.
Trying to understand what was going on in the system as a whole, I decided to look at Laguna Honda specifically and ask myself, what had gone on there in the last 20 years? So I figured out that in the last 20 years, as a cost-cutting measure, the patients we had, had gone from about 1,178 down to 780. This was as a cost-cutting measure. So we were taking care of a lot fewer patients.
Of course, correspondingly, the number of doctors we had went down, was cut, from 32, to nine. And, correspondingly also, the clinical staff, that’s the nurses, and the therapists, and the social workers, was also cut as a cost-cutting measure, from about 15,000, to 1,200. And yet, at Laguna Honda, every year the budget has increased.
So I asked myself, well, what counted for that? And I realized that even though the patients were fewer, and the doctors were considerably fewer, and the clinical staff had been cut, the total staff was actually the same. There were more and more administrators every year. What did all those administrators do, I asked myself? Well, what I realized was that, when I thought about it, that the one thing we had more of at Laguna Honda at the end of my time there, than at the beginning of the time, were forms. So when I first got there, we had paper charts. And we had two single-page forms in the chart.
And the day before I left Laguna Honda, I pulled out one of the paper charts just randomly. And I started looking through it. And I counted how many forms that were. There were 43 forms in that chart. And none of them were single-page forms. They were 10 page, 20 page. There were so many forms that the charts would explode from the forms. And medical records had to show up and thin out the doctors’ notes. And this, to sort of clarify things, because I do have somewhat of a mathematical mind, I created this chart at the time when I was figuring this out OK, now this is working.
So this is a chart I created at the time on a napkin, as Becca pointed out the other day. So these are the patients, going down, I was trying to understand this system. There are the doctors, going down. There’s the budget going up, the clinical staff, the total staff staying about the same. And this is the number of forms. And what I realized is, is that if current trends continued, by 2024 there would be no patients at Laguna Honda. There would be two doctors. There would be a staff of 1,400, a budget of $275 million, and an infinite number of forms. And I began to think of this as doing less with more.
And the thing that’s interesting about it is — and crucial about it — is exactly the same as the thing that’s been happening in the country as a whole. Let me show you what I mean. So this is the country as a whole. So if you look at the growth of its physicians and administrators, here’s what you find. So I’ll interpret this a little bit for you.
These are the number of docs, percentage growth. So it’s about doubled. So the docs have about doubled, in tandem with the population has about doubled. So there’s about the same number of docs per patient, and vice versa, as there always have been. The yellow is a number of administrators. There are 35 times as many administrators as there used to be. And as you can see, just like Laguna Honda, the budget has continued to go up every year. And what do all those docs do? What do all these administrators do, I should say? Well, this just is interesting. This is HHS paperwork. Really, they should say electronic computer work, in millions of hours, millions of hours.
Just in the last 10 years, it has doubled. From 350 million hours, it has doubled to almost 700 million hours. Why? Well, what’s happened is, is that because of all this paperwork that the administrators have generated for various reasons, we’ve ended up in a situation where your doctor doesn’t have enough time to look at patients anymore. This is a sentence I’ve heard over and over again over the last five years as I’ve gone around and spoken about the book. And I put it — I don’t know if you can see when you’re sitting here.
But this was a rather scandalous drawing that appeared in the “Journal of the American Medical Association” a few years ago. A doc had it published. It was a mother who brought it to him. It was a drawing by her five-year-old daughter, about my visit to the doctor. And you can’t see it too well. But this is the daughter sitting on the exam table. Behind it is the mom, holding a little baby, and a friend, I believe. And this is the doctor, who is looking at the computer. This is where we’re spending our time.
And from experience, in general, and experience, particularly at Laguna Honda, I believe in or to have a good health care system, we actually need to put inefficiency, that is unregulated free time for the doctors and the nurses to have the time to look at their patients and to get off the computer.
And the question then becomes, how can we get that time back? Because, as you’ve just seen, we have actually the same number of doctors and patients as we’ve always had. But the doctors are spending a bunch of time, not with the patients. So that the patient doesn’t feel looked at anymore and isn’t looked at anymore.
So when I was thinking about this, trying to figure out, OK, so how could we get the time back, I asked myself, well, what do we spend our time on? And, in a way, time is the viriditas of health care. So I can do a viriditas analysis, and ask myself, well, what is in the way of doctors having enough time with patients? What do doctors spend their time on? So I came up with three fundamental things doctors spend their time on, forms; what I call fast administration, as opposed to slow administration; and lousy electronic health records.
By forms, I mean this whole contraption that has come upon us with electronic health records and administration, screens, logins, alerts, e-mails, script, that are based on this whole idea that if it’s not documented, it didn’t happen. And if it is documented, it did happen. And we can talk about that a bit. And second, what I’m thinking of as fast administration, which I consider a problem with style. This idea by administrators, that if they come up with a form, they’re done.
If they come up with a paradigm, a script for us to follow, the problem was solved. And last, and really mainly, the easiest thing to fix, to get doctors back their time, electronic health records, that take all our time. And this is what I’d like to sort of zero in now on for little bit, about the problem with electronic health records and how I think we can actually get doctors back some of our time with patients, some of our free time, some of our inefficient time. So we can sit down with patients, look at them, and actually examine them.
So what’s happened in the past about 10 years is electronic health records. We used to use the paper charts. The biggest flaw with paper charts was that, if you went to the emergency room and nothing happened, and then you came back to your doctor, they couldn’t tell you what — nobody knew what was going on. We had to get them to send us, to Xerox things, and send the paper.
So more than about 10 years ago, what they did is that if we had electronic health records on the computer, and you went to the emergency room and had something done, it would magically appear in your doctor’s office, on the doctor’s computer And so that’s kind of was the way that electronic health records were envisioned
But that’s not what happened Because there’s so much money in health care these days, and so much money in electronic health records, at this point, the last time I checked, there were 1,100 for-profit electronic health record companies And they’re engineered to that they don’t talk to each other So it’s actually even worse than it used to be So how bad is it? Well, doctors have ended up– so first of all, the electronic health records haven’t done what they should have done.
But, in addition, they’ve been used to acquire big data for the pharmaceuticals, marketing, and advertising. And the doctor has been right in the middle of that. The doctor has been plumped in front of the electronic health records, which are based on a model of — based on an old billing model, that comes back from the 1970s and is incredibly clumsy. So clumsy that in a Stanford study, doctors were actually spending 70% of their time on the computer. But in a more sort of shocking study, Kaiser got tired of hearing how whiny their doctors were about how much time they spent on the computer.
So they actually decided to see how much time do our doctors spend on the computer. And they picked two hospitals. And they spent two months actually keeping track of all the stroke doctor — all the keystrokes. And then they added all that time up and they divided by the number of doctors. This was in two separate hospitals over two months.
And they discovered that the doctors, out of an eight-hour day, were spending 10 hours on the computer. So this is where our time is going. And we could get it back if we had electronic health records that only took as much time as the paper records, which would take about 15% of their time. So in a 15-minute visit, they’d take 2 and 1/2 minutes of time, rather than taking more than 15 minutes of that 15-minute time. We can get the doctors off the computer, back to doing the kind of care that I was able to give at Laguna Honda, where we can actually get the right diagnosis and the right treatment.
So that’s actually what I’m focusing on now and one of the reasons I wanted to speak up to this particular audience. Because I think it’s very possible to create an electronic health record that’s simple, that’s cheap, that takes, like, 2 and 1/2 minutes instead of 15 minutes, and that everybody could use and would want to use.
So some of my rather larger ideas for getting control would be to have the opposite of the three things I had before about what we spend our time on. So we could start in terms of forms, with a law for the conservation of forms. So my experience is that we have enough forms already and that we don’t need any new forms.
And I think in most hospital situations, that when an administrator comes up with a new form, they should find at least one form of equal length to get rid of. Second of all, slow administration; I think that if administrators would think and would realize that every time they send an email, organize a meeting, or come up with a new form, they are directly taking time away from the doc. And last, we need the electronic health record that preserves story. Because the problem with electronic health records based on the billing platform — I don’t know if anybody here has ever seen them. But they make it literally impossible to understand what’s actually gone on with your patient.
And the last thing that I think we need to do in our health care system is to also start some experiments with being slow. And some of the ideas I’ve come up with for that is to just, in the hospital situation, to have a slow medicine clinic, where the doctor would get as much time as they needed with patients. It’s a novel idea. Slow medicine beds, so that we had a few beds in the hospital where patients could be admitted when they needed a work-up, instead of getting piecemeal, being sent all over town when they get sick.
And finally, a slow medicine consult service. That would be the equivalent of an oncology consult service or a cardiology consult service. But it would be for slow medicine, for the patients that we end up as doctors getting in the hospital, that are so sick and complicated. And we know we cannot figure out what’s going on with them and we have to discharge them.
Instead, we call it the slow medicine consult service. And have them arrive, and figure the patient out. Because in the end, I’m not a complete pessimist about health care. I’m a pessimist and an optimist I think that health care is — with health care, the glass is half full and half empty, in this way. That, in a lot of ways, we’ve done a fantastic job with fast medicine.
That this model of the body as a machine and the doctors as a mechanic has been incredibly powerful. If you look at what’s happened over the last 150 years in medical history, nobody would ever want to go back to practicing medicine the way we did even 20 or 30 years ago. But on our way to fast medicine, this idea that doctors would have enough time to get the right diagnosis, to examine the patient, to get the right treatment has sort of disappeared. And I think we need to go back and reinstitute this second way of looking at a patient.
For more on my book, which some of you have, and last, I always like to remember who, in the end, won that race.
So thank you very much for your time. We’ll have some questions and answers.
REBECCA MOORE: Thank you. We do have a Q&A. I do have a question to start with. But people, please think of questions for Dr Sweet. So you’re here at Google. And a big focus for us now is machine learning and AI, which is being applied to all facets of human endeavor and actually creating a lot of breakthroughs. Do you have any thoughts on how machine learning and AI could, in fact, play a role in solving this problem with electronic medical health records, that lose the story, doctors spending too much time as data entry clerks? Your thoughts on that.
VICTORIA SWEET: Yeah, I do. So that’s really the issue of the hour. There’s 1,100 different electronic health records systems. But they all look exactly the same. They’re all fundamentally the same. And they all lose the story. They’re little bits of information. They’re boxes, that the docs have filled out. The old paper charts were basically books. They were basically books. And they preserved the story of the patient. They were books because they had pages. And they went through time. They had a beginning, and a middle, and an end. And this was incredibly useful as a doc because you could go through and you could read about how the patient first came in, and the things that were done, and what the nurse thought, and what the social worker did, what meds they were on, and what labs. It was very useful for serving the story.
And then what happened when electronic health records came in, because they were built on this piddling platform, electronic health records that we look at today, what the doctors are all looking at, is a screen. And it’s a screen with boxes, and alerts, and logins. So the doc is sitting there, logging things in. Pharmacy has got a whole different section. Nursing has a different section. And these are all little boxes. And you cannot figure out from the electronic health records what’s gone wrong with the person. I know this because my own father got sick a couple of years ago and was admitted to a hospital with the wrong diagnosis. And this particular hospital, at the time, the doctors and nurses were actually reading “God’s Hotel” in their book club.
So I was a bit of a VIP. Nevertheless, I could not get those docs to change his diagnosis. They thought he’d had a stroke. But he hadn’t had a stroke. He’d had a seizure. And he had a history of seizures. We all knew he had seizures. I couldn’t get them to focus. They even tried to change the diagnosis in the electronic health record. But they couldn’t change it.
So every time a new shift of doctors and nurses came down, they continued to treat my dad with the treatment for a stroke. And eventually, he was on so much medicine, the medicine for the stroke, and then medicine for the side effects of the medicine for the stroke, and the medicine for the blood pressure, kind of this sort of thing, that he was clearly going to die in the hospital. So I was rather worried about him. And I realized the only way I could really get him out of the hospital was to convince the doctors that we thought — we had decided he was a hospice-level patient. And we were wanting to just let him die.
So once they accepted that, they let us take him home. And I took him off all the medicines that he was on. And he had his 95th birthday about two months ago and cut his own cake with a very large knife I mean, he did it on purpose. So I thought perhaps I’d missed something because I couldn’t — there was no chart for me to look at.
And I was worried, well, maybe he did have a stroke I mean, maybe I’m wrong. So I asked for those electronic health records, his electronic records, from 10 days. And I got them. And it was amazing. It took me four hours to go through those electronic records of my dad’s. There were 810 pages. I had two questions I was trying to answer. What medications was he on at any particular time? And why had they made that diagnosis of stroke? And I could not figure it out. I couldn’t figure out anything.
It was just page after page of — it was just — there was no way. And I spent four hours. And I knew what I was looking for. So nobody who came to see him, when they looked at those electronic records, could possibly have figured out what was wrong with him. So when you compare these beautiful old-fashioned paper charts, it would have been easy.
I would have just gone through and looked at his original diagnosis, how he got it. I would have turned back and looked at the labs, which would have been in a section. I would have looked at the X-rays. I could have seen the nurses’ notes. I could have followed the doctors’ narrative. I could have followed the story. It would have been a snap. So my idea is that we take this model, this old-fashioned model, that’s made out of paper, and we just turn it into electrons. So we have an electronic paper chart that preserves the story. And how would we do that? So my imagination is that we already had this technology. It’s called an e-book. So why not just use this idea of an e-book for our electronic health records?
So if you, for instance, came into my office, you were a new patient, we have some HIPAA privacy-protected cloud, that I can take a new chart out of. That’s your chart. And it looks like a book. It’s on the computer. But it looks like a book. And I should be able to, I think, I should be able to — if I like to write, how come I can’t, like, handwrite a note? Or if I like to dictate, why can’t I? If I like to type, I should be able to do that. If I want to write in French, I should be able to do that. I should be able to write the narrative of what happens and my physical exam. I should be able to turn that chart around, go look at– fluff through the chart.
Why can’t we do that? And then that would mean that if we did it this way, then when I’m done with your chart, I put it back in the cloud. Let’s suppose you have to go to the emergency room. They can just go take that chart out of the cloud and write in it themselves. I don’t see why you can’t do that. And so then the problem becomes, well, what do we do — because one of the reasons electronic health records are being used this way is for billing. And the second reason is because of big data. Oh, big data is very valuable. This idea that you can figure out instantly how many patients have hypertension, or how many patients — this kind of information is very valuable. Just financially, it’s very valuable. It’s valuable to marketing. It’s valuable to pharmaceuticals. It’s valuable to the health care industry as a whole. But right now what we have, is we have the docs acting fundamentally as data care providers. That’s what we do.
REBECCA MOORE: Data care providers –
VICTORIA SWEET: Data care –
REBECCA MOORE: OK. That’s a new one.
VICTORIA SWEET: We put — that’s our job. We spend 110% of our time in front of your electronic health records, simply entering data, so that big data can be produced. So that big data can be sold and used by these companies. And so what I don’t — it seems to me — Becca and I have actually talked about this — is, if artificial intelligence can do all these marvelous things, why can’t they take my handwritten notes and all this stuff and just stick artificial intelligence between the necessary big data and my electronic paper chart, and if artificial intelligence turned my chart into all the big data you want? Why do I have to do it?
REBECCA MOORE: It works for me. So that is your challenge.
VICTORIA SWEET: Yes I challenge Google.
REBECCA MOORE: OK. The gauntlet is now thrown.
VICTORIA SWEET: Yes I think we should do that. Because if we could do that, it would be phenomenal. We could have doctors who could spend 2 and 1/2 minutes — we’d have our 12 and 1/2 minutes back with patients, to examine them. The big data people, who like all that stuff, they’d still be happy. And you guys could do something fantastic. And I think it would be very interesting for artificial intelligence to look at that as a problem.
REBECCA MOORE: So I have one more question. But then I want to let other people do it too. So in the news this week — I think it was just like yesterday or the day before — it was suddenly announced that some of the health policy setters have changed the standard for hypertension. And they’ve lowered the level of your blood pressure at which they consider that you have a problem and should go on medication. And I think I saw yesterday, that now 50% of the adult population is now considered hypertensive. And, in fact — then I heard on NPR last night, something about someone, who is sort of an apologist for this, was saying, but it’s OK. We’ve determined that it’s safe to medicate people at these lower levels of blood pressure. So it’s fine. I found that alarming. And I just wondered if you had any thoughts on this.
VICTORIA SWEET: Yes. Well, I do have clients. Well, so my first thought actually was — so they’ve been doing this for decades and decades. So long ago, when I was in medical school, and they had actually — so the way that docs determine what’s high and what’s low is — we don’t really know actually. It’s mostly statistical. We basically decide one standard deviation from the mean, or two standard deviations from the mean, by definition. That’s what we do. Because we don’t — A priori, we wouldn’t know what a normal sodium is.
The way we even know a normal sodium is we do billions of sodiums in people. And then we declare these to be normal, within, let’s say, one standard deviation. And everything else to be abnormal. And then, sometimes, we’ll be able to connect up a disease state or a symptom with those abnormalities. So with hypertension, that was done in around the ’60s and ’70s. And the original definition of hypertension was actually — I may be one of the only people who remember this — was actually about a 180 over 110. That was two standard deviations from the mean. And that was correlated with significant kidney problems, when you have that high a blood pressure, heart problems, and extra strokes. So that actually was actually shown as evidence.
Then, over the years — but that’s two standard deviations. What do you get, 7% of the people are taking their medications. That’s not very much. That’s not very good. So about, um, about 20 years ago, they lowered — they just randomly lowered, and said, from now on it’s going to be one standard deviation from the mean, which is 160 over 90, which nobody has ever correlated with actual damage. But they just assume, if really high blood pressure was bad, then kind of — this was still high. It was one standard deviation from the mean.
So then we had in an epidemic of high blood pressure because suddenly we had 15% of the people had – statistically — you guys are all mathematicians. Once you go from two standard deviations to one standard deviation, you have 15%. So, my god, we have this epidemic. Because it used to be 7% of people had hypertension. Now, 15% have hypertension. But then, we have 15% more people taking medications, which is very useful. So then about –
REBECCA MOORE: I think you’re being sarcastic.
VICTORIA SWEET: –15 years ago, we declared that 140 over 90 was hypertension. So then we had about 20% of people who were now hypertensive, about 20% of people. And then the cardiologists got together and decided that any amount of blood pressure was bad for you. They did. They did. Remember? They did do that. But they didn’t really officially declare it until this last week, where they’ve lowered it once again, down to 130, which falls actually way within the mean, the mean of a blood pressure. So consequently, 50% of — it’s not surprising that 50% of people now have hypertension with the definition. How would they not, just statistically? And that means 50% of people are going to be on medications.
REBECCA MOORE: Do these medications have side effects?
VICTORIA SWEET: Yes. They all have side effects.
REBECCA MOORE: OK. Anyway, I’m asking too many questions. Anyone else have a question for Dr Sweet?
VICTORIA SWEET: Or a comment?
REBECCA MOORE: Or a comment?
AUDIENCE: All right. I have a microphone.
REBECCA MOORE: OK. Great.
AUDIENCE: He’s up front.
VICTORIA SWEET: Yeah. Go ahead. Actually, you –
AUDIENCE: Comment on that. How much is that mean shifting over time though, since the ’60s?
VICTORIA SWEET: What do you mean?
AUDIENCE: Well, you said it’s so many standard deviations from the mean.
VICTORIA SWEET: That’s right.
AUDIENCE: And now, are –
VICTORIA SWEET: So the mean stays –
AUDIENCE: Is that mean shifting itself over time?
VICTORIA SWEET: No. So the mean — All right. I see what you’re saying. That’s a really interesting question. That’s actually a very good question. As far as I know, the mean is still the average-ish. It’s still about 120 over 70, as far as I know. I mean, that’s actually a real interesting question. I don’t know the answer to that. I don’t know if anybody does. Do you know — I think it’s still 120 over 70. It’s just, they keep coming down, just like they’ve done with statins. It’s exactly the same model.
I mean statins, your elevated cholesterol was two standard deviations from the mean, which was going to be an LDL, a bad cholesterol of, like, 180. And then they went to 160. And then they went to 130, which, again, meant that 50% of the people, not surprising, were hypercholesterolemic, because that was, like, within 50% of the people had a LDL of 130. And then the cardiologist declared that it doesn’t really matter and we should have as low cholesterol as possible, even though the white matter of your brain is white because it’s made out of cholesterol. And your sex hormones are made out of cholesterol. And vitamin D is actually 1-dehydroxy cholesterol. So, yes.
REBECCA MOORE: All right.
VICTORIA SWEET: Salim?
VICTORIA SWEET: Did I get your name right, Salim?
AUDIENCE: So I will have my question about forms and administrators for later maybe. But I’m more curious — or maybe I’ll start with the preface that we’re a part of a technology company. And it certainly feels like the world is moving faster and faster. And we want to, whether it’s multitasking or enabling people to move faster, you put a lot of the onus on the medical system and doctors to slow the system down, it seems like, to not treat the body like a machine. Yet, what are your thoughts from a patient’s perspective? The ability to take some ibuprofens when I have a headache and solve the problem is — that’s nice to hand that off to the doctor and say, why are you prescribing me ibuprofens? But I can get this off the shelf. How do patients approach medicine differently and slow things down, and look for longer solutions, moralistic solutions?
VICTORIA SWEET: That’s a really thoughtful question. Thank you. Well, what I would say is this, I think there’s actually two flavors of patients, two flavors of people really. Some people really like medications. They like meds. They like labs. They like going to the doctor. They like — they just like it. They like meds. And then there’s a whole other group that don’t like meds, of which I happen to belong to them. And what usually happens with docs in an open system, is the docs that like to prescribe meds and just naturally practice this way, collect patients who like to have medications.
There’s a whole lot of people who believe in meds. But I’m not one of them, either as a doctor or as a patient. And I would tend to collect patients who think like me. So I don’t think it’s just one or the other. I think for the people who are reluctant to take meds, they don’t usually take meds very much. And if they can get away with just taking something off the shelf, sort of why not? So I think that’s how I would answer that question. I’m not sure if I got to the nubbin of it. Because you started out by talking about everything moving faster and faster.
And that as a patient, how can you get things to slow down? And in a way, I don’t even think it’s as a patient. It’s as a person I mean I think– so this is, again, maybe a little off for me talking about. I think as far as our health goes, we couldn’t live in a society that was more difficult to be sane, and centered, and enjoy your life than the society you live in right now. And I think– you know, “sane” actually is from “sanus,” which means “healthy” in Latin. And “health,” which is “solus,” actually is connected to salvation. Then I like the one that’s “hello,” which actually means “health to you”. Because in old English, “hal” was health. And they’re all related to this idea of wholeness. So whole, and hal, and health, and wealth — I think I haven’t looked that up yet.
But I decided the other day, I think wealth fits into this wholeness model. We’re fragmented. Our attention is fragmented. We’re just in this kind of piecemeal, sort of state. And I think it’s not a good state to be in.
AUDIENCE: Building on Salim’s thing, I think he says — I think it’s separating symptom from the source. So if you have a headache, and that’s a symptom, you say, I can take an Advil. And that will go away. And you can just keep doing that for a while. But you’re not addressing the root cause. So if I can treat a symptom, I will deal with it myself. But if I can’t get past that, then that’s where I go to the doctor, to help me figure out what’s actually going on.
VICTORIA SWEET: Correct answer. Thank you.
AUDIENCE: Well, you’re supposed to comment on that.
VICTORIA SWEET: Oh I totally agree with it. It’s exactly right. That’s exactly it, is if you can make it go away on your own, and that’s — then, I don’t have a problem with that actually. I think that’s a good way to go.
AUDIENCE: That’s your measure of efficiency though. Are you looking at — efficiencies? I had a headache today. I took a pill. It went away. It looks like it’s extremely efficient. But if every single day I’m taking this pill, and I’m constantly dealing with that, over the long term, that’s extremely inefficient. And if I treat the source of that, it takes me longer to treat the source, but it solves it for a much longer duration. And therefore, it’s much more efficient in the long run.
VICTORIA SWEET: Good answer. It is. It’s super. Thank you.
AUDIENCE: To get to Salim’s point, I think it’s very hard for a certain segment of patients to get over that. They want the quick fix. So, in some ways, many physicians respond to that by prescribing I think many– and I speak as a physician myself. Many of us would like to sit down, talk to our patients, spend time. And sometimes patients, like me, doc, I don’t have time for this. I’m not going to invest in my health care I just want — give me the antidepressant and I’ll feel better. And I’ll have time for therapy later. But I don’t have time for that right now. So there’s this whole sea change, that has to also start from the patient point of view, actually wanting to invest time in themselves.
AUDIENCE: And if you have to see a thousand patients, you don’t have time to do that.
VICTORIA SWEET: Correct.
REBECCA MOORE: Anyone else? So one last question, maybe. Do you feel that you, as a clinician, that you are alone in this? Or, as you go around and you’re talking with other doctors, and nurses, and so on, around the country, is this message of slow medicine resonating?
VICTORIA SWEET: Yeah. It sure is. And I sometimes wish I was a lot more of a general, rather than a philosopher. Because there’s a whole movement that is brewing out there. There’s so much frustration among doctors, and nurses especially I mean as much nurses, as doctors. That, we’re just stuck in front of the computer. It’s just maddening. So there’s a huge– I’ve spoken to, like, thousands of people by now, personally, in all these different talks. And everybody wants something done about it, which is one of the things I’ve thought about electronic health records and getting– because that would at least get us off the computer. It’s not complicated. I don’t think it’s as complicated a solution as it looks like at first, if we can just get back the time.
REBECCA MOORE: OK We’ll have.
AUDIENCE: Since we’re at Google, I’d be curious about your comment on the use of Google Glass in the doctor/patient setting. So a clinic, that I will not name, has now gone to using Google Glasses. So you walk into the clinic, the room. Your doctor has a Google Glass on. And on the other side of the Google Glass is a transcriptionist, probably in India somewhere, outsourced, that is documenting every single word that occurs between you and your physician during that encounter. So in some ways, it’s taking more time. The doctor doesn’t have to do the data entry. But there’s this third person in the room, through the Google Glass, that your wonderful — an amazing company has enabled doctors to use this technology.
But it has affected the doctor/patient interaction. Many of my colleagues who are using it, claim that it’s given back their lives. That they’re now completing all of their charting within the course of the day. They’re going home. And they’re not taking their charts home with them because they don’t have to because everything is transcribed for them. But I’m wondering, from all of you, and from you, what your perspective on this as a possible solution would be?
VICTORIA SWEET: That seems to me not a solution, but a possible problem I mean – I just – I was just horrified when I heard about that. I mean, I can’t imagine anything worse than going into my patient like this. Hi I’m Dr Sweet, trying to look at the Google Glass and their records out of the corner of my eye. It just seems whacked. There is something called the Scribe, which– it gives me the same feeling, which is doctors– so they don’t have to sit in front of the computer.
Now, there’s an actual, physical third person, who follows you in the room and fills out your electronic health records, while you supposedly are talking with the patient, which is, as an example, a lot better solution, I think, than the Google Glass, where at least you’re physically looking at the person. But Rebecca, do you have any thoughts on Google Glass?
REBECCA MOORE: Well, actually I have a clinician who wanted to do that. And I was uncomfortable. And she did give me an option, that you didn’t mention, which is– what I was uncomfortable with was Google Glasses, about looking at things. It’s not just about audio transcription. And so it could be beaming images, right, which feels like it could be a violation of the patient’s privacy. So there were two modes.
So the mode that I allowed her to use was just recording audio. But even so, that eyewear, I felt as an imposition in that trust relationship, personal. Anyway anything else? Oh, one — Yes, please.
AUDIENCE: You have to have this paper trail of absolutely everything. And that’s part of what’s inhibiting your efficiency.
VICTORIA SWEET: Could you say it a little –
AUDIENCE: How much of it is driven by legal reasons, and not like big data and collecting?
VICTORIA SWEET: Oh I see what you mean.
AUDIENCE: By having a paper trail and –
VICTORIA SWEET: Yes. Yes. Well, we have we do like to document things for malpractice reasons. But if you just handwrite it, it’s perfectly fine. It doesn’t have to be in a computer per se, at all. So there’s no reason that we have to have a clumsy electronic health record, that takes all our time and produces big data, in order to document. It’s actually much better documentation if I actually write the story about you. This 32-year-old woman came in with chronic headaches. And I thought this. And we did this. And this is what I think it is, kind of the story, than it is to have what I found with my father, which was incomprehensible.
So that’s not the legal thing. There is a legal piece that the United — the one reason we’ve gone to having electronic health records was that in 2009, there was hidden in the Reconstructing America Act, this little — what did they call it– sorry– this little sublaw thingy, that every doctor, that has anything to do with the federal government I think, has to have their electronic health records. That’s how it happened. It didn’t happen gradually.
It was like 2009. And then they would start taking money out of your practice if you didn’t have electronic records. So it was one of the reasons that suddenly they took this billing platform and just immediately tried to add things on, so they could sell it to the doctors and doctors could do that. So there is some legal piece of that. But it isn’t so much like getting sued, kind of thing. It’s more like government.
REBECCA MOORE: I do want to point out that Dr Sweet is one of the few people on the planet who’s actually read the entire Affordable Care Act.
VICTORIA SWEET: 922 single-spaced pages. It’s as long as Harrison’s “Principles of Internal Medicine.”
REBECCA MOORE: OK. On that note, thank you very much.
VICTORIA SWEET: Thank you very much for having me.