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“Physicians have terrible technology, but they refuse to recognize high-tech as a medical specialty. They must integrate technology as they do laboratory science.

Physicians are certainly suffering from poorly-designed electronic medical records (EHR), but they are also guilty of wilful blindness in abdicating responsibility for technology in medicine. This must change.

Physicians have a higher suicide rate than post-combat troops in the military. A lot of this is due to widespread burnout from poorly designed EHRs. Yes, it sucks, but who is really at fault?

What if this problem was a consequence of a professional stance medicine can choose to reverse? What if it won’t go away until we do?”

Drea Burbank is a physician-entrepreneur.

She shares her story and discusses her KevinMD article, “Why doctors are getting their asses kicked by technology.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow. Today on the show, we welcome back Drea Burbank. She is a physician-entrepreneur. Her KevinMD article is titled “Why doctors are getting their asses kicked by technology.” Drea, welcome back to the show.

Drea Burbank: Well, thank you for having me.

Kevin Pho: So for those who didn’t get a chance to listen to our first episode together, just briefly share your story and journey to where you are today.

Drea Burbank: Yeah, so I grew up off the grid. I was a forest firefighter for 10 years, became a doctor, and after medical school, I went and did high tech in Silicon Valley. I did go back to clinical medicine. I tried really hard to get back, and then I just decided that I was having more of an impact in high tech.

Kevin Pho: So what are some examples of the impact that you’ve had as a physician in high tech?

Drea Burbank: Well, actually, I think physicians have an interesting role. I both promoted telemedicine in 2014, and then I also helped to regulate e-cigarettes in 2015. In recent years, we consulted for a wide variety of high-tech companies trying to make it into medicine, trying to kind of yenta that arrangement such that it was beneficial for all involved: physicians, patients, institutions, and the high-tech companies. And then recently, we’ve launched a fair-trade carbon offset platform where we work with small farmers, so we’re looking more at population health in areas that are war-torn.

Kevin Pho: Now, you’ve worked a lot at that intersection between tech and medicine. In general, how accepting is the tech community of physicians and physicians’ views?

Drea Burbank: Yeah, that’s a great perspective. I think in general, the tech community sees physicians as combative, and I think they have very little context on why physicians would be resistant to adopting technology. I also think that many doctors do cross that somewhat of a divide, and then they’re very much respected for their clinical assessments of technology.

Kevin Pho: So when you say that tech companies see physicians in general as combative, what are some examples of that?

Drea Burbank: Well, I think as a technologist, when I say that I’m an MD technologist, physicians are like, “Well, what’s a technologist? Is that even a thing?” And there’s no competency behind it. So there’s this kind of attitude of, “That isn’t a thing, and all I’ve ever seen in my clinic is horrible software.” And while I 100 percent agree that what most physicians have seen in their clinic is horrible software, what they see on their iPhones is good software. And that’s not made by accident.

But it is somewhat of an esoteric trade, in that tech develops so fast, and the techniques to develop it are changing so fast, that it’s actually learned as a trade on the ground by people working in these tech hubs. So it’s not actually taught in schools, and physicians really don’t have a view of that trade. And it’s hard for them to see through the 90 percent of the noise to the signal sometimes.

Kevin Pho: So in general, when a tech company wants to create a product that is meant to be used by physicians, do they make an effort to incorporate some of that clinician input?

Drea Burbank: It depends on the tech company. I think almost anybody who’s been in technology for any length of time has gotten burned by some form of medtech. Usually what happens is somebody will come in, have a good idea, develop a good product, and then try to sell it and just run into complete stonewalling in the market. They won’t be able to sell it to anybody, and the tech company will go broke. So a lot of venture capitalists and a lot of technologists have gone broke trying to bring good technology into medicine.

And on both sides of the divide, I think there’s frustration. For doctors, all they see is that no good tech is coming at them, and they don’t really know the institutional factors that are arrayed against good technology coming to them.

Kevin Pho: All right, so let’s talk more about that. Your KevinMD article is provocatively titled “Why doctors are getting their asses kicked by technology.” Now, for those who didn’t get a chance to read that article, just walk my audience through it and share the story of why you decided to write it.

Drea Burbank: Yeah, actually, it was really funny. I was talking to a friend, and I was saying that the technology in medicine is so bad that it actually merits a class action. Doctors could form a nationwide body and sue, because the technology they’re getting from institutional software developers is far below industry standard. Just from the developer end, they’re not meeting their contracts. And then my friend said, “Well, why would doctors do that?” And then I thought, “Oh, you know what? They don’t actually have any context on what the problem is.” So it was kind of a two-article series, and I wrote the first article to try and explain to doctors why things were so bad, so that they were aware they had some power.

Kevin Pho: Yeah, so let’s go more into that. From your perspective, give us some insight. Why is tech perceived as so bad by the physician community?

Drea Burbank: I think it’s a combination of two things. First, physicians are very much specialized. They have to spend years and years and years getting really good at what they do. And what they do is a combination of knowledge, just a deep, deep depth of knowledge of the human body, disease conditions, and their specialty, treating patients. It takes 10 or 12 years to really get a sense of what they’re doing. And then there’s also this very esoteric thing that can really never be digitized, which is how to make a kinesthetic evaluation of a patient and talk to them, handle tough emotions, and deal with esoteric issues like death and dying and childbirth and disease. These are all things that can’t be automated.

So physicians have very deep knowledge in basically two areas. The one area where they could be helped is this concept of information: how information gets to them and how they document their information. There are good tools for that. The area where they can’t be helped is this more esoteric, kinesthetic, and intuitive area of assessing patient conditions holistically, physical hands-on skills, and emotion management, kind of the healing arts. A lot of times what I see is that tech companies try to take on both of those tasks, and they tend to discount the healing arts because they don’t understand them. They haven’t done it, and they haven’t been in these very intimate environments that doctors spend all their lives in.

On the information transfer side, a lot of times physicians can’t necessarily articulate what would make their lives easier. Oftentimes what they ask for is not what would actually help them. That’s common in all tech development. Most technologists know that you don’t necessarily develop what the person asked for; you develop what they use. And you basically use other signals to determine whether your user is happy, like whether they’re downloading your app, how many keystrokes it takes for them to get something done, or their faces while they’re looking at the app. You use something called heat maps to see where they’re scrolling over the screen, and if they have to scroll down five or six pages to get something done, you know that you’ve put that button too far down. So what people ask you for is not always what they want. And there’s a bigger discrepancy with doctors, because what they think they want is oftentimes not what would actually help them.

Kevin Pho: Now, for those who aren’t familiar with how bad health IT or EHRs are perceived to be, give us an example, from the physician standpoint, of some of the problems that they’re facing when using a typical electronic health record.

Drea Burbank: Yeah, God, I know this intimately. OK, so I did three years of health tech development, just wide consulting across the industry: lots and lots of different startups, developing product, engineering, everything. And then afterward, I went back and did a surgical residency for about nine months. As a preliminary-year surgical resident, which, I mean, obviously is kind of the lowest grade of medical deployment for a doctor, you were in a mind meld with that EHR, and we had a terrible EHR. So I had intimate, play-by-play, daily, 12-hour exposure to how bad the software was.

And I think it was especially painful for me because I actually knew that it was that bad. Doctors, I think, have kind of a holistic assessment: “This is terrible software.” But I knew each and every element of why it was terrible. Every time there was a bug, I could see it. There was no reporting; there was no way to report a bug. There were no IT services for the software. There were 200 elements on the screen and seven clicks to do basic stuff. There were all kinds of medication errors. You name it, it was in there.

So I 100 percent sympathize when doctors say they have bad technology. They definitely do. But I think the problem is that physicians think that somehow it’s difficult to make this technology. It’s not difficult. It would be very easy to repair that technology or provide a better one, but there is no free market for it. The company that was providing the software that I used had no competitors. They had already sold the software. They had absolutely no incentives to support or repair or enhance it. And that’s the big problem with medical technology right now.

Kevin Pho: So these companies, knowing that they have no competition, do they have any insight into how bad their technology is perceived to be?

Drea Burbank: Yep, they do. I mean, everybody who develops technology does. There’s a specialty in computer science called human-computer interaction. There’s a set of software development tools. There are specialists who only look at how the human and the computer interact and how easy the software is to use. That is a well-recognized specialty that has been around for at least 10 years. Every major software company, like Twitter, Instagram, all these ones that everybody’s using on their phone on the side, they all have these specialists. Health IT doesn’t have any of that, because they don’t have to pay for it, because they are institutionally embedded. They don’t have any incentive to pay for that extra service.

Kevin Pho: So what do you see as the path forward in the next year or so when it comes specifically to EHRs? A common complaint is that EHRs are clunky, too many clicks and whatnot. But what do you see as a path forward, especially if some companies have a monopoly and there’s really no incentive for them to change? What’s a path forward that physicians can look forward to?

Drea Burbank: Well, the first thing I think physicians need to do is they truly need to organize. This has to be a nationwide play. I think Eric Topol wrote a brilliant article about why doctors should organize and how doctors have been balkanized by external forces. And I think this is the perfect use case for doctors to organize. So I read an article called “Why doctors should organize.” They need to organize, and then they need to insist on two things.

First off, software companies can be reported to state and national bodies if their back-end database does not transfer over electronically. So any software company that insists that the patient record, when it’s transferred, is exported on a CD can be reported to the state and federal organizations for non-interoperability. That’s number one.

Number two, I believe that doctors need to form a class action and force software developers to open the interface to third parties. In other words, it’s just like your iPhone runs a suite of apps, and everybody has a different suite of apps, depending on their personal preferences and what they do. There’s a free market for these interface apps that run on top of your iPhone back end. And right now, historically, we basically have very large-scale databases like Epic that comprise a large number of the hospitals in the U.S. If Epic is forced to crack their software interface open to a free market, I think that physicians would very, very rapidly find they have a huge suite of software tools available to them that actually are HIPAA-secure and usable, and they can use their buying power to pick which apps are working and which ones aren’t.

Kevin Pho: Now, short of organizing or having physicians bring a large class action suit against a major EHR developer, is there anything on a more localized level that they can do to help improve the situation?

Drea Burbank: I think just knowing what’s going on is helpful. There’s this concept of learned helplessness. Basically, if you feel like you can’t escape a situation and you’re getting electric shocks, you just kind of lie down and you feel awful. If you see an outlet or a way to escape the situation, then it helps a lot with the cognitive pain of dealing with terrible software.

So I think physicians can, first, just understand the historical context of where we’re at in medtech. There are two basic principles that every doctor should understand. One is the Gartner hype cycle, which is how a technology gets overhyped and then how it actually begins to yield. We’re seeing that with Bitcoin right now, but we’ve seen it with AI. We’ve seen it with a lot of things. So that’s called the Gartner hype cycle.

The second one is called diffusion of innovation theory, and it’s absolutely critical in medtech, more critical than, I think, in any other discipline. That’s how technology is refined as it crosses the population, depending on your capacity to deal with technical errors versus your pragmatism. I’ve written an article about it, but I think doctors are professionally pragmatic; they’re in the pragmatist category of diffusion of innovation theory. But if anybody can look at diffusion of innovation theory and realize where they’re at on that spectrum, then it really helps to contextualize the problems that they’re having.

And then the third one is that a lot of doctors do get involved in medtech, and just knowing the other side of it can oftentimes alleviate a lot of the stress. There are some great doctors doing some amazing, usable, HIPAA-secure software in their spare time. There’s a group in Toronto that has a really, really slick and well-done clinical patient intake form, and it’s just super well developed. I’ve seen doctors go through Y Combinator with software that you can adopt to replace the paper charts that all the residents use. It’s HIPAA-secure. That kind of software can be adopted right away. It does make life easier. It was designed by clinicians, and it’s usable. And I think just being able to find those kinds of solutions and implement them can make a big difference in physicians’ mental strain from software.

Kevin Pho: I agree with you that we do need more clinicians on the medtech side to give, certainly, a perspective of what’s happening on the proverbial ground. So if a practicing clinician is listening to this, what kind of advice do you have for them if they want to cross over and involve themselves in the medtech society?

Drea Burbank: Well, I think first, decide where you fit on diffusion of innovation theory. Do you like tinkering with software? That would put you in the techie category. Do you feel like software has the potential to make your life easier? If you see a lot of potential for it, that puts you in the visionary category. Or do you want your software to just work, and only work, and do something useful? That puts you in the pragmatist category. A late adopter is next, and that’s somebody who only wants it once their friend is using it and it’s working for them. And once you know which one you are, then it’s a lot easier to figure out how you want to interface with technology in general.

So, for instance, if you were a visionary, somebody who really saw a lot of potential for software, a doctor might want to get into the investment end. A lot of doctors dabble as angel investors. And I do suggest that doctors, if they want to be angel investors, just go to a few angel investing events. You’ll meet other people who are looking at technology from a pragmatic perspective, and you’ll get a chance to see a lot of technology companies coming in that may or may not be useful. And it’s a good chance to kind of kill off the ones that shouldn’t be around and then promote the ones that should. You don’t necessarily have to put money into an angel investing group to go to the event.

Some doctors develop their own technology, and I think that’s a much tougher road, to be a founder. But it’s nice to have an outlet for the passion that people feel. And I have seen some lovely technologies. One just came out: An internal medicine resident from Stanford just made one where doctors can look up the price of medication at the time of prescription, so they get a clear view of whether or not their patient can buy it with their current coverage.

Kevin Pho: We’re talking to Drea Burbank. She is a physician-entrepreneur, and the KevinMD article we’re talking about today is “Why doctors are getting their asses kicked by technology.” Drea, any take-home messages that you want to leave with the KevinMD audience?

Drea Burbank: Yeah, just that I have so much compassion for doctors right now. Being in clinical medicine is one of the toughest things that I think anybody can do right now. And I really, really strongly believe that doctors can advocate for themselves. They do have the capacity to change the system, and finding out what’s going to work for them individually to do that is kind of the key. But I’m always here. People can reach out. I’m more than happy to give resources. Our website has a section called Tools, and it has a lot of the resources I mentioned.

Kevin Pho: Yeah, thank you so much for your time and insight. Thanks again for coming back on the show.

Drea Burbank: Thanks for having me, Kevin.