Within healthcare workflows, miniscule problems or hurdles can have a compounding impact on complexity. An extra click on one page within an electronic health record (EHR) can turn into dozens of extra clicks over the course of a day. This ‘sludge’ can slow down or eliminate efficiencies, burn out physicians, and ultimately result in worse care for patients. Conversely, finding solutions to those speed bumps can have an exponential impact, not only with respect to the streamlining of workflows, but enhancing clinician and patient satisfaction, and improving overall business performance.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Graham Walker, MD, physician and co-founder of MDCalc. They discuss his background in the emergency room, how he came to co-create a clinical support decision tool, and what’s next for him in the entrepreneurial realm. They also talk about small inefficiencies that lead to wider problems, the threat of an IT ticket blackhole, and the new trend of rounding for clinician well-being.
Listen here:
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READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[01:06] Dr. Walker’s background
[07:29] The beginnings of MDCalc
[14:13] Dr. Walker’s next company
[22:00] EHR steering committee and other tech responsibilities
[25:03] In-person rounding for clinician well-being
[31:20] Inefficiencies within the health system
[38:34] Overcommunicating with physicians
[45:19] Dr. Walker’s favorite well-designed things
[48:44] Outros
Transcript:
Dr. Craig Joseph: Graham Walker. Welcome to the pod. How are you, sir?
Dr. Graham Walker: Hey, it's so good to be here. I'm wonderful. Thanks for having me.
Dr. Craig Joseph: Where do we find you today?
Dr. Graham Walker: You find me in my lovely office, wallpapered by me and my husband. We did not kill each other. We're both alive and well. We wallpapered my lovely office. I'm about two blocks from Golden Gate Park here in San Francisco, California.
Dr. Craig Joseph: San Francisco. And are those plants native Californian plants that I'm seeing?
Dr. Graham Walker: You know, he's the green thumb. I don't even water these things. He is kind enough to water them and care for them.
Dr. Craig Joseph: All right, fair enough. You're pleading ignorance. Here's one thing you cannot plead ignorance about how you got to where you are now. I always like to kind of start with, hey, were you a young child and thinking, boy, I'd like to go to medical school, practice emergency medicine, and also, have a technology wing to my career, start a couple companies, do all of that. Was that something that you were thinking in nursery school?
Dr. Graham Walker: Yeah. Craig, this was my 40-year plan. Yeah, when I was four, I manifested this, and I just decided this is where I want my career to go, and then I just made it happen. I'm that dedicated and focused and have that much foresight to know where my career would take me.
Dr. Craig Joseph: Excellent. Well, I like early starters like you. And you're the kind of person that we want on this podcast series.
Dr. Graham Walker: So, I was gifted and talented in elementary school.
Dr. Craig Joseph: Oh, my god, it’s getting deep in here. I thought I was the king, but you have just dethroned me. That's awesome. Well, so let me ask you this. When you were going to medical school, what kind of doctor did you want to be?
Dr. Graham Walker: I think emergency was always in the short list, partially because of the show “ER.” I was in high school when that was having its heyday. So that was always on the list somewhere. And then I think it's easier to know what specialties you don't want to do than the ones you do. And so, once I finally did my ER rotation, I was like, oh yeah, these are my people. You know, dry wit, sarcastic, hardworking, a little bit of ADHD, get bored of a patient after more than two hours, you know?
Dr. Craig Joseph: Yeah. No. That's great. Obviously, there's an age difference because I thought you were going to go down the road of Emergency, like Squad 51.
Dr. Graham Walker: Oh, yeah. No, I know that existed as a show, but I can't say I've ever seen an episode.
Dr. Craig Joseph: All right. That is disappointing and will count against you. As we calculate your score at the end of the at the end of the show. So, then you went and did an emergency medicine, residency. Where did you train?
Dr. Graham Walker: So, yeah, I trained at Saint Luke's Roosevelt. It's technically now Mount Sinai West and Mount Sinai Morningside Heights. Really rolls off the tongue there, but I will forever call it Saint Luke's Roosevelt. In Manhattan in New York City, on the West Side. And, yeah, incredible place to train. Incredible group of attendings and nurses and colleagues and lifelong friends now.
Dr. Craig Joseph: And did you have any kind of, tech training or, and I asked to foreshadow because clearly, you've started at least a couple of companies.
Dr. Graham Walker: No, I certainly attribute a lot of this to my dad, he's a psychiatrist, but also a computer nerd guy. We would go to CompUSA and get the latest Pentium processor, a 486, and I was so excited. I would play computer games after I had installed the 12 floppy disks to get one program to one game to load. So I grew up learning from my dad, MS-DOS, how to show a file directory and open word processor files and then Windows 3.1 and then, really the internet really started, the information superhighway started when I was in high school. So, I had time to teach myself some HTML and JavaScript and taught myself a little bit more in college. But there were no college classes that taught the web at all. You had to take C or C plus. And I was like, I'm not doing that. So, I kind of used online tutorials and taught myself more web stuff. And then that's been where my sweet spot has always been kind of on web development, web technologies. So no formal training. But certainly, I grew up around computers my whole life and still spend way too much time on computers today.
Dr. Craig Joseph: Well, that's fair. And I think, as part of the computing public, we appreciate the time that you've spent on and computers.
Dr. Graham Walker: Shoutout Don Walker. Thanks a lot. Thanks, dad.
Dr. Craig Joseph: I'm sure he's listening. Yeah. He's a big fan. He's told us. Are you from California? How did you go from New York to the other side of the country?
Dr. Graham Walker: I'm from Kansas. I'm a Midwesterner, from Kansas City, from the burbs, the burbs of Kansas City, Missouri. And I lived on the Kansas side, so I'm a Kansan, went to Chicago for undergrad and then Stanford for med school. And then, I always had a fascination with New York. I thought, oh, perfect. Three years in New York can decide if I want to stay there longer. But, got drawn back out to California, did a fellowship out here, back at Stanford again, and then have been practicing here in San Francisco ever since. So finished fellowship in 2012. So, yeah, it's 14 years now.
Dr. Craig Joseph: Okay. And you've been at KP the entire time. And so, you're a practicing emergency medicine physician. Most people kind of find that as a full-time job. Yet you and, I think one colleague put together, something called MDCalc, how did that come about? And what is this MDCalc that people are talking about?
Dr. Graham Walker: Yeah. Emergency medicine is a full-time job. I do find ER doctors tend to be some of the more entrepreneurial groups of folks. I think part of it is the shift work thing. Part of it is the challenges of just, our whole shift is just dealing with people who are having the worst day of their lives. So, we see all the problems in the system, in our face. So, yeah, in med school, 2005, I was getting asked questions on Ranson’s criteria, which is like an ancient score from the 1970s about pancreatitis and asked, oh, if I knew the criteria. And I was like, of course not. Why would I memorize these 12 esoteric criteria? And, when there's a computer two feet away and realized that there was not a place where all this stuff was written down or it wasn't a website that had all this bunch of different sites, had a few different scores, but nobody had everything. So, I decided, oh, I'll just build this thing because this clearly is a problem that needs solving. That tends to be a common theme with my brain is like, oh, I see inefficiency, I see a problem, and then I want to solve it. So, I would just go home from the hospital every night and just code and then come back the next day. And then I think two weeks into my rotation, I showed it to the interns, and they were like, sorry, what did you do? What did you build? And so, I thought, I figured that was a good validation, a good thumbs up. And so, then sort of thinking, okay, how many scores can I find? And I would go through the little number, those little pocketbooks with four-point font that we carry in our white coats.
Dr. Craig Joseph: Yes.
Dr. Graham Walker: So, I would just skim those and try to find scores. They were often printed in little tables. So, they were a little bit easier to find. It was like these various criteria for cardiology and the metabolic acidosis, Winters’s formula to correct that, all that stuff. And then right after residency, my co-resident Joe Habboushe, shout out Joe, my co-resident Joe was a year ahead of me in residency is an MD and an MBA. Extremely brilliant and savvy business mind, an emergency physician. Importantly he approached me and said, hey, I think what you've built with MDCalc is really valuable, and it's really cool what you've done. What would you think if we teamed up, if I joined you? And we went from, you just running everything to say hey, we could build a business around this, and I said, oh, clearly, I'm not the savvy business mind here. I had Google AdWords on the site, and it was paying my cell phone bill, my gym membership. And I thought, what else do I need in the world?
Dr. Craig Joseph: Yeah. Big money.
Dr. Graham Walker: That's resident mindset right there. And Joe said no, I think, I think it really could be a true business. I think it could really help even more people. We could grow it. And I said, oh, okay. Sure. Let's try it. I never really thought of it as a business. I just thought of it as like a thing that I'd built. And so certainly with, all to Joe's credit, Joe has figured out how to turn it into a sustainable business. And, yeah, we're used I think millions of times a day, maybe it's millions of times a week, but I think it's close to millions of times a day. Physicians all around the world, we have, I think, over 800, maybe 900 scores on the site. And the idea is if a doctor has a question about, a particular patient and how they should manage them, we probably have a score that might help them take care of their patient with an evidence-based kind of research tool. So, we review that, review the research ourselves, make sure it kind of meets our standard. Then we put up MDCalc on the website, on our free apps. It's all free. And then, then people use it, and it hopefully helps them take better care of patients. We're used, we think by about two thirds or about 70% of US physicians every month. So, in a lot of doctor's pockets and hopefully helping a lot of doctors with their patients.
Dr. Craig Joseph: Yeah.
Dr. Graham Walker: Which is what drives me. That's what that's what excites me, is like, oh my God, I just it's so cool to see how much good this thing has done in the world is the way I look at it.
Dr. Craig Joseph: So, but what I think is most important is you never answered the question, what are those criteria?
Dr. Graham Walker: Yeah, I would it's something about calcium, but it's like calcium 48 hours later because that used to be how we would manage pancreatitis. We would just put you in a hospital and check your calcium level two days later to see. It's like the pancreas had eaten up your calcium.
Dr. Craig Joseph: Yeah, that's good. And, I think our audience will want to know what the attending physician did, who was asking you questions, and how did he or she responded to your answer of: no, of course not. Why would I memorize that? There's a computer right over there.
Dr. Graham Walker: Now that that tone and response is something today's Graham Walker, would not respond well, but I think the medical student, Graham Walker, was a little bit more politically savvy enough to not really respond in that sarcastic tone. But it was it was one of the, chief resident, who I think is now an interventional cardiologist at Stanford. Hi, Monica! Yeah, I think, maybe she can take some credit there.
Dr. Craig Joseph: She was okay. She did not destroy you.
Dr. Graham Walker: I was, I was not made to feel less than for not knowing Ranson's doctor Ranson's criteria.
Dr. Craig Joseph: Okay. All right. Luckily for you, wasn't me. Because you would have a different outcome, for sure.
Dr. Graham Walker: Well, my pediatrics rotation. Now let's talk about some hazing.
Dr. Craig Joseph: We pediatricians are known for that. So, my understanding is that MDCalc, which again is kind of leveraged by almost three fourths of physicians on a regular basis. That's not enough for you. And so, you've got another because your ambition knows no bounds. You've got another company that is not, not officially out there, but you're teasing it around called Off Call.
Dr. Graham Walker: We're teasing it to, to a select group of physicians and hopefully having a public launch, a public kickoff in sometime later this fall. So, in about a month or so, maybe when right around the time this podcast drops. And it's a tool to try to improve the health and the well-being of physicians, that again, back to a problem that I'm seeing that gets under my skin and I can't let go of. I'm just seeing a lot of physicians, Craig, who want to leave the bedside, who want to leave medicine. I don't think that burnout or moral injury is the right term necessarily anymore, but I'm just seeing so many physicians who are just kind of tired and fed up and don't want to do it anymore and are hearing from other colleagues that you could do something else, that they're you could do a side job, that there are other avenues for doctors and that just honestly, this might sound hokey, but for the health of our profession and of healthcare, that really bothers me. It really scares me that everybody, every day, people are just looking for a way out or maybe, oh, I'll go down on hours or I'll, I'll stop doing XYZ. And so, yeah, we're building a platform to collect information about what makes a good job a good job, what makes a bad job a bad job in terms of like a clinical job. Right? It's not just the pay, but it's how many patients you're expected to see per hour. And do you have administrative support or is everything a hassle to try to make change and all that stuff? Plus, some content to around what I'm kind of calling para-clinical stuff, it's not directly, stuff that you have questions about seeing a patient, but the stuff that's related to the stuff about seeing a patient, the meta stuff. And then some kind of social community tools to try to help with some of the, I think, connection that we've lost. What medicine has lost during Covid. You know, bring back a digital physician's lounge, try to get people to connect, whether it's over clinical stuff or it's just finding ways to network and get to know other people who are interested in similar stuff or reconnect with your friends from residency. I mean, there's so many reasons that I think physicians would love to, reconnect with each other. I think medicine's just gotten lonelier than it used to be. We're all so busy, we don't have nearly as much time for those watercooler types of conversations where you end up collaborating with somebody you didn't think you were going to collaborate with, or getting to know somebody that you thought you had nothing in common with or finding friendships or ways to deliver better patient care, all that stuff.
Dr. Craig Joseph: Well, I for one will be signing up and looking forward to all the fun conversation. I'm particularly interested in how you design this, right? How are you facilitating these conversations. Go ahead, just give us the answer.
Dr. Graham Walker: Well yeah, it's all figured out, we're done. We launched yesterday, and we figured it out today. It's all good. It is going to be an interesting challenge to get, I think physicians, we typically bucket ourselves by specialty and I'm talking to another ER doctor. I immediately trust them, like them, whatever. But it's like, oh, a pediatrician or, cardiologist. I don't know if I can trust them or if I like them. So, I think that is going to be one of the bigger challenges for us is, moving this idea, getting people to buy into this idea of we're kind of we're stronger together, more transparency and more information for all of us is better. You know that it is going to be a change, but it I think it's a necessary change that we start to work together more and collaborate because the current state of affairs, I don't think is working very well. So, I want to change it and try to improve it.
Dr. Craig Joseph: Yeah, I'm kind of fascinated by how, I think we don't realize it till we start talking it through. But the job description is pretty unhelpful. To say, should I, should I go to this health system, or should I go to that health system? Doesn't really, matter. You know, you can’t decide based on without talking to someone like, hey, am I supposed to handle all the incoming patient portal messages or someone taking most of those from me and just tiny little things like that? It's almost never what's happening in the exam room. At least on the outpatient side. Right. It's the things are outside. And those are hard if you don't ask that question and then have that available in a discreet way for me, if there's no good clinical support, I'm not even looking at this healthcare system. And, and then that makes it better for everyone because that healthcare system certainly quickly learns like, oh, bingo. You know, we're going to have to invest in, in more medical assistance or yes, I have someone, but they just seem to forward all of the messages right to me.
Dr. Graham Walker: And this is the exact thing that I love, Craig. Is, is every time I talk to a physician about it and just kind of, start the conversation going just like you did, they literally complete the sentence for me. I think people really get it that this thing hopefully is going to work and that there is going to be benefit. Again, if we agree or we choose to use the thing. So, I'm hopeful and excited.
Dr. Craig Joseph: It's great, I spent most of my time in the clinic, as a pediatrician. That's where I was. But we didn't have hospitalist. I'm very, very old. Graham, we really didn't have hospitalist. And so, one of my partners or I had to go to the hospital every single day to see our patients. And as we're seeing newborn babies, I'm seeing colleagues from other offices and all of that's now stopped, some of it because of the pandemic and things change. And others, because we have hospitalists now and certainly efficiency is helped. That's great. I wasted a lot of time driving. Sometimes I go to three hospitals in one morning. Just because that's the way it was. And so, I would go to three hospitals to see five patients.
Dr. Graham Walker: And your note was like three lines.
Dr. Craig Joseph: You know, from a financial perspective, that was not a good decision, but, yeah, it's changed now and maybe the efficiencies are up, but the humanity is down and it's no good. Yeah. No bueno. So, let's talk about what you're doing now outside of your family of companies. So you mentioned that you work at Kaiser Permanente and that you've got some you have some outside of, emergency medicine, some other clinical responsibilities. So, what are some of the other things that you do tech wise at least?
Dr. Graham Walker: Sure. So, I've been on our steering committee. So, we use we use Epic we call it KP HealthConnect because we like to have our own lingo for everything, in our organization. So, it's called KP HealthConnect. And so, I sit on our core team, which is essentially our kind of a governance and steering committee for emergency medicine and for urgent care. And it's a great group. It's a meeting that I look forward to every week because as the people in the meeting are all super fun. And I mean, you would love and probably know a lot of these people. You know, it's the people that care deeply about the nerdy informatics stuff, about the challenges of building a new order set that has good usability and is not going to confuse people, but it does not have so much level of detail that people are just going to refuse to even open the thing or look at it at all. And everybody's really driven to improve patient care that is always at the center of everything. So, it's nice to be in a group that's so focused on, hey, how can we do this better? That's literally the focus of everything, which is great. And it’s such a diverse group of physicians and nurses and pharmacists and, and from artists from around our region, from I think we probably have maybe 60% of specialties, maybe 70% of specialties represent. So, you get to hear from, well, how is this going to affect the hospitalist or the ER doctor, or interventional radiology or the outpatient spine surgeon or the plastic surgeon? You know, you hear about how this one little thing is going to oh, well, if we do that, it's going to really screw things up for X group of people. It's kind of like politics. How do you manage all of those all of those constituents and everything.
Dr. Craig Joseph: And so, is it true that you don't just care about what's going on with emergency medicine to the detriment of every other specialty? Is that not accurate?
Dr. Graham Walker: If I was in charge, certainly the only thing we would do is emergency medicine. But unfortunately, we do have to take some consideration into the other fields, of medicine, even though they're clearly not nearly as important as the inferior.
Dr. Craig Joseph: Inferior? That's right. You're looking for one of the things, that you brought up when we were preparing for this episode was, in-person rounding. And now rounding is something completely foreign to you as an emergency medicine doctor. We do these things. I mean, I say we, I mean, real physicians. We would go and see patients in their hospital rooms up on the floors. I know, it's confusing to someone like you. We would round and just go all around the hospital to see these various patients. They weren't conveniently located in a small room. Probably. What, 20 by 20 is the size of your emergency room? I would imagine.
Dr. Graham Walker: It is one room. We pack them in like sardines.
Dr. Craig Joseph: Yeah, so this was, something that was introduced to you and where you got to do in-person rounding, but you weren't rounding for patient care. You were rounding to see how it was for clinician care. I would say, maybe tell us about this.
Dr. Graham Walker: Yeah. So, I, one of one of my roles that I, I just ended it, earlier this year, I was the assistant physician in chief for technology for my medical center. So that's kind of like a CMO to some degree. You know, it's a mixture of tech operations, training, reporting outages and bugs, troubleshooting issues, educating clinicians. You can never over educate or communicate a change coming to anything in technology. And we started this, six months before Covid, but one of the ideas we had were just, it's kind of like this similar idea of death by a thousand paper cuts, all these little subtle annoyances that are too small to quote un quote, make an IT ticket for or two insignificant for somebody to then follow up on the ticket if it didn't get fixed. And so, you just deal with it. You do the work around, but it's just a little thing that is so annoying. And they often never get fixed because they're too low on the totem pole of priorities. And so, our idea was, well, okay, let's just go to go to the gamba, go to where the sausage is made, go to where the EHR is being used, and just walk around and see if we can help people with these little annoyances, that we know exist. I mean, I know they exist because I see them in the ER, or I see them anywhere I'm working. They just exist everywhere, not just in healthcare, everywhere in the world. But we would just go to department, kind of myself on the physician leadership side, one of our, IT technical leaders, a trainer, an Epic trainer, who could answer just questions about how do I do X, Y, Z more efficiently? It would be one of our, site support people who can go into the back end of the EHR and make configuration changes, and we would let the manager, and the chief of the department know, hey, we're going to show up on Tuesday afternoon. Is that an okay time for you? Sounds great. And then there'd be like six of us who just show up and we say, hey, we're here. We're here from IT. How can we help you? And sometimes it takes a little bit to get people to remember what's annoying about their stuff, because either it's so ingrained or they don't do the workflow frequently enough. But several examples stuck out in my head. One was, a medical assistant who gives all the vaccinations in, I think, our adult and family medicine department. And she I think she's been doing it for 15 or 20 years. And there's all this paperwork because you have to give a little hand out about the vaccine, a paper handout by law or whatever to the patient. Maybe I have to sign something I can't remember. And we just watched her working, just kind of qualitative interviewing almost. And we saw she would multiple times a day, she was clicking a button. And then she would just disappear for 30 seconds. We're like, where are you going? And she's like, oh, well, this thing that I print out for vaccines every day prints out across the hall. It's no big deal. I just have to do that. And I was like, wait, how many times a day do you do this? And usually, I don't know, 10 or 20. And so just thinking of course the solution is she didn't know, and we hadn't told her that we could remap that workstation to a printer, that there was literally a printer right next to her. And again, it was just one of these small annoyances that she was like, oh, I guess that's how it works, that there's not a way to get my computer to talk to the printer. Right next to me. I just have to do this 20 times a day. And so, we saved this, this woman thousands of steps a week for this silly workflow. Because it was just too low priority. And I think also, I said before, I don't think she was aware that it was fixable. Or maybe somebody told her it wasn't fixable, or maybe it used to not be fixable. I mean, these are all possibilities. That's the challenge of the progress of technology is getting down to a medical assistant and letting her know, hey, we've made these improvements and changes and fixes, but maybe they take a little bit of configuration to make happen. And I don't know that any large organization can really do that effectively. And so that is I think that's why the IT rounds was really successful was we were able to bypass all those layers of bureaucracy and get right to the end user and just say, hey, what can we fix what's broken?
Dr. Craig Joseph: Yeah, I love that. And it's a great story because there's so many things in healthcare while probably in all kinds of different industries. But so many things and you go into any hospital or office, and you see kind of horrible, settings that are completely changeable, that either no one changed, or no one asked about or someone asked, and it went into some help desk death spiral. Yeah, just disappeared and the story I love to tell, it's actually in the book I co-wrote is talking about my daughter, who I took to a university clinic for headaches when she was a kid. And they were using Epic as well. And at that time, I actually worked for Epic. So, I was watching the MA or nurse, whoever's rooming us put the information in and she went to the reason for visit, which was two boxes. One was a dropdown box. She had to choose something, and the other was a free text box. And again, this is at a pediatric neurology clinic.
Dr. Graham Walker: Probably sees headaches a lot.
Dr. Craig Joseph: I don't know I'm not here to judge. Went to other, selected other because there was no headache of course. And then typed in the word headache and, and I asked her that same question that just made I mean, I asked her the question I already knew the answer to. Do you see a lot of kids with headaches that here in the pediatric neurology clinic? And she said, why, yes, we do. And I said, but I don't see it on that dropdown list. And she said, no, no, it's not there. And I said, it could be there. She goes, oh, it could, yeah. Did you ask anyone about it. And she said no I don't, I don't think we can now. She said when we went live a year ago that it used to be a piece of paper where we put things that were broken. But I don't even know how to tell someone now.
Dr. Graham Walker: Yeah. Or who would I tell?
Dr. Craig Joseph: Right, so it's these little things. A similar story when I was the CMIO, I got much more credit and thanks from physicians when I fixed a documentation template that had a typo in the third paragraph in the second sentence that they went in and fixed every single time because they're anal retentive, as what they should be if they're physicians. And, when I said, hey, how about that cardiology module. You know that costs $5 million. Yeah. And it's like, that's all right. But you really made my day. When you fix that typo. And that was not sarcasm. That was the truth. So, it's these little things, and you don't discover them unless you're walking around. Even if you ask, like you said earlier, half the time they don't. No one even remembers, as this woman didn't.
Dr. Graham Walker: And there's so many layers between that nurse and the decision maker who decides what the dropdown could include. That’s the other challenge. Say she reports it, it becomes probably a ticket somewhere. But then how does the ticket person know how to get it to that decision maker who might not be in IT? They may be a clinician, they may be, a nurse Informatics, but maybe they're not in the same org structure or it goes into the ticket black hole somewhere.
Dr. Craig Joseph: Yeah, yeah. And I tell you another thing there, I think having folks kind of understand, at least even a little about the technology that they use every day, the major tool is, we don't ask why enough. Why is that printer not working next to me? And why do I have to type? Why do I have to choose something from a list anyway? If I have just a free text box, what is the benefit of that? And that I happen to know since I worked at that company at the time, I said to the nurse, if there was a selection for headache and you chose it, we could put smart sets or order sets and documentation templates. We could queue them up for you. They'd be ready there for you. You wouldn't have to go and choose them. And she said, oh, that would be helpful. I said, yes, yes it would.
Dr. Graham Walker: You know, Craig, right before medical school, I would make people little websites like little small business websites. In my free time for just some from extra cash because I was working for a nonprofit and wasn't making much money. And I did one for, I think, a roofing company or something like that. And the owner was a very nice guy. I can't even remember how I met him. But he would call me incessantly and say, the website's down. And I was retentive as I was, I’m like no, I'm sure it's up. And sure enough, I would type in the website name, and it was up, it was working. Everything's working. And he kept telling me, no, the website, it's back down again. And I would be losing my mind. And this was 2002. So, it's not like there were cell phones, it was hard to take screenshots. I went to this guy's house, and I was like, can you show me the website's down? Because the website's up for me. And so, I'll never forget this. I watched this man, who was not a tech guy. That's not his job. I watched him, open up Netscape or Internet Explorer or whatever it was, and he would open to the Google Home page, and he would type in the domain name into the Google search bar. And this was before we had one bar at the top of the browsers that would do search and address bar lookups. So, he would type in whatever it was. ChicagoRoofing.com, I don't remember. He would type that in, and because I hadn't submitted it to Google or Google, didn't know about it. And Google at the time didn't just also refer you and say, oh, you typed in a URL, did you mean to just go to that URL and make it easy to click on it? And so that was such a life lesson of, oh, we are just speaking a different language. I'm technically right, but what the client is saying, I had to go to see exactly what he meant, because once he showed me, I immediately understood everything about it and I was able to solve it. Right. I was able to say, okay, yeah, let me submit this site to Google. I got it submitted to Google. And a week later, what do you know? The site was never down again. So that was the other get curious not furious thing where it's like sometimes it's just have to go see what the hell the person's talking about and have an open mind and not be increasingly annoyed, as I'm sure I'm able to get especially with my lovely parents who I try to do tech support for and I think it's hard to not get frustrated with your parents and doing tech support for them.
Dr. Craig Joseph: I like that phrase get curious, not furious. I'm going to have to remember that. One thing I wanted to just touch on a little bit in the time we have left is something you said, a few minutes ago. It's almost impossible to over educate, I think physicians or over communicate with physicians. Can you dig a little deeper into that? What do you mean?
Dr. Graham Walker: Let's dig. I can dig deeply on this one. I'll give you my opinion and my working theory. You cannot overcommunicate, to a physician when it comes to, oh, a change to the EHR or a new way that you're going to be doing XYZ, right? Maybe it's not a tech thing at all, but it's like, oh, we have a new way that we're going to be doing paracentesis, or there's a new kit, or there's a new IV pump or whatever it is, you cannot over communicate it. Because the number of times I have what I thought was over communicate something like I have, hey, there's this big, massive change, like Epic introduced this thing called storyboard. This was probably 4 or 5 years ago, and it was going to change dramatically what the EHR was going to look like. And so, I sent emails, I did screen share videos. I think I probably made a jingle or something like that. I mean, I really tried to communicate this and we have a whole structure of technology leaders in each department who also their job is to help communicate out these big sweeping changes so that nobody gets confused on day one. And what do you know? I got three emails from physicians, in all caps angry. What did you do? Nobody told me this was coming. I can’t order my steroid cream. You know, whatever it is, I can't find the patient's phone number. Whatever. And so, that lesson was just that doctors are busy. They don't always check their email. They don't always attend the staff meeting where maybe this was discussed. They don't always attend whatever the leadership meeting with the CEO where I've even asked the CEO to, hey, just show this slide. Just tell them, hey, ask Graham if you have questions. But just so they've seen it once, so it doesn't look totally shocking to them. And still even then, and I was working with 600 physicians. So, it's a lot. But it's not thousands even then, still multiple people. I've never seen this. What are you doing to me? So yeah, you cannot overcommunicate, it is literally impossible. And it's probably also just the, the innovation diffusion curve, some people are going to adopt storyboard immediately and totally get it. And other people, maybe they have seen it, but they're just confused by it, or they're scared by or it, they've lost their muscle memory. And that's so critical to them getting through their day because they're not good with computers or whatever. So, I get it. But yeah, that that was the takeaway from my work.
Dr. Craig Joseph: So, despite all of your attempts to design, multiple different, modes and ways to get to them, there's still some you're never going to get to.
Dr. Graham Walker: Yeah, and I think accepting that just comes with the territory and that certainly I think early on I maybe would have viewed that as a sign of failure, that I had done something wrong. And at some point, you just accept that part of the diffusion curve, part of the change management is going to be, you'll probably get a few emails. So just be ready the day of to reply to a few emails and that's also just part of the process. It's not a sign of failure. It's just an expected part of change management too.
Dr. Craig Joseph: Sure. Yeah, I learned a lot from watching my cell phone change. There are apps that I thought are great, and I got them totally packaged and figured out. And then overnight, the button, my button has been moved, and it really irritates me. Or there's this thing that used to be one click, and now it's multiple. And I hate it. And if I had your phone number or your email address, I would have emailed you and complained about this on my app. And it might be that's how I deal with off call and MD, but we're like, yeah, well, we'll take that later. But then if you wait a couple weeks and, and someone says to you hey, I know you were upset about that change in that app. Do you want to go back? You want us to make it go back? Go back to the way it used to be? Myself personally, and almost everyone I know, they'd be like, what are you even talking about?
Dr. Graham Walker: Yeah, I think that's a key reflection, Craig. And it's something that I think, , internally, we could have tried to do a better job on is reminding people of how far we've come. So there really, truly, is value in just scribbling down a list of the ten improvements or changes that we made in the past year. And it helps remind people like, oh, God, remember when we had to carry pagers or remember when we had to write triplicate prescription pads? And if you didn't have your pad, you had to go bother your neighbor and ask them to write some Norco, whatever it was. So, I do think that's part of just the human condition. It's not even a doctor thing. It's just part of the human condition that we have the ability to forget. To some degree, forgetting is a blessing. But we are always going to be looking at the next annoyance. We will never be fully satiated. Oh, you got rid of pagers for me. That's enough. It's like, okay, well, no, we got rid of pagers, we switched to a secure texting app, but now we need these extra features for the secure texting app. That's just the human condition I think, again it's not a failure. It's just how human brains work.
Dr. Craig Joseph: Well, Dr. Walker, we have come to the end of our time on this podcast episode,
Dr. Graham Walker: What?
Dr. Craig Joseph: I know, I know.
Dr. Graham Walker: Say it ain't so.
Dr. Craig Joseph: Before we let you go, and I'm using the royal we, I like to always ask people at the end of our interviews, since we like to talk about healthcare and design. Are there things in your life, is there 1 or 2 things that are so well-designed that they bring you joy and happiness? Do you have 1 or 2?
Dr. Graham Walker: I do. I was talking with, with the NerdMD guys about this, Adam and Dale, there's an app called…
Dr. Craig Joseph: Wait, wait, timeout. We're not going to talk about the NerdMD guys on this podcast.
Dr. Graham Walker: Can we start over?
Dr. Craig Joseph: No, the whole thing's done. The whole episode will now never be seen. All right, keep going, keep going. We're going to let it go.
Dr. Graham Walker: There's an app. There's an app for Mac called Raycast. If you use a Mac or even Windows 11 now has this kind of, searching tool as well. Right now, Raycast is just for Mac, but it's coming to Windows from iOS. But the idea is super nerdy, but with just keyboard shortcuts, you can control everything about your computer. You can hit one keyboard shortcut to open up a certain website. You can hold another keyboard shortcut to connect to your Bluetooth headphones. Another can open up the dictionary app, another can do complex automations and talk to AI. It has the ability to launch applications, search your files, do all sorts of automations, and it's pristine, well-optimized for keyboard people like me. So, you can kind of dance your fingers over the keyboard and get your whole configuration set up for working efficiently. Right. So, I could open a browser window and have it taken up the top left of the screen. And then I could open another browser window, and have it open up a podcast app, and then another browser window could open up Spotify in my second screen. You know, it's hyper-configurable, to a fault. And for people that like control over their computer like I do, it's an extremely well-designed app and it's free. Also, I highly recommend it for everybody.
Dr. Craig Joseph: Awesome Raycast, alright. And it's only apple right now, but at some point.
Dr. Graham Walker: Yeah, I think they just got $30 million of funding to bring it to Windows and iOS. Big fan.
Dr. Craig Joseph: Regarding the controversy from a minute ago, I've been handed a piece of paper that now reminds me that Adam Carewe has appeared on this podcast, and Dale Gold is scheduled to appear on this podcast. So, I will have my comments struck from the record. Well, thank you so much. It's been a great conversation, really enjoyed having you. And I hope everyone checks out MDCalc and off call when it's available and read your LinkedIn commentary because it's brilliant. And if they ever need, if they ever have an emergency, when in San Francisco. I hope they seek out your care.
Dr. Graham Walker: Yeah, honestly just stop by my house. I mean, I might not be working.
Dr. Craig Joseph: You just go to Golden Gate Bridge, and you just scream Graham. Is that how that works?
Dr. Graham Walker: Yeah, it's like a bat signal.
Dr. Craig Joseph: You'll come, or you'll go in the other direction depending on what the need is. All right. Well, in all seriousness, thank you so much. Really appreciate it and look forward to all the great things in your future.
Dr. Graham Walker: Thank you. Thanks for having me, Craig.