Malcolm Gladwell on Fixing the US Healthcare Mess

Editor's Note: In this edition of One-on-One, Medscape Editor-in-Chief Eric J. Topol, MD, sits down with best-selling author and journalist Malcolm Gladwell, who shares his unique perspective on healthcare and the practice of medicine. Mr. Gladwell believes that reform in healthcare might begin if, at its most basic level, the practice functions as a cash economy. He also notes the frustration clinicians feel after being saddled with technology that has become more of a hindrance than a help, and believes that ultimately providers need to be allowed more time to spend with patients, and fewer mandates, if healthcare is to prosper.

Dollars That Are Not Well Spent

Eric J. Topol, MD: Hello. This is Eric Topol, editor-in-chief of Medscape. I am delighted today to welcome Malcolm Gladwell, one of the most accomplished nonfiction writers of our era, if not the most accomplished, and a person who has written a fair amount on science and healthcare. We have been talking with some of the most interesting people in the world of medicine, and sometimes it is best to go outside of medicine.

I thought we could start with something very funny. You are on Twitter, and you have a few hundred thousand followers but you don't tweet very often. Recently you tweeted about the John Paulson $400 million donation to Harvard. It was hilarious. Can you tell us about that?

Malcolm Gladwell: I rarely tweet, and I didn't imagine that these tweets would have the impact they did. I forgot that anyone was even reading my tweets.

I was in the back of a cab and was struck by the absurdity that a very wealthy and very intelligent man would think that it was a good use of his money to give $400 million to the richest educational institution in the history of the planet. For someone who spends his life thinking about good returns on investment, that is not a good return on investment. I think is appropriate to hold wealthy people, who are donating tax-deductible dollars to charitable causes, accountable for their choices and to encourage them to make good choices.

Dr Topol: It was funny. You called it "the John Paulson School of Financial Engineering."

Mr Gladwell: If billionaires don't step up, Harvard will soon be down to its last $30 billion.

Dr Topol: Have you had any backlash from it?

Mr Gladwell: Very little. Mostly it was other billionaires who objected.

I don't think it is any great mystery in America that our dollars are being misallocated. We are spending resources in the wrong places. That has gone from a rumble to a roar, and people have had it.

There are plenty of very worthy state institutions around this country, with lots of talented people who are either learning, or teaching, or researching, who are desperate for money and who could do extraordinary things with $400 million. There is a justified sense of inequity in American right now.

Should Home-Run Drugs Charge Home-Run Prices?

Dr Topol: That is a good segue to American healthcare and medicine. There are many new drugs that cost $100,000, or even up to $400,000-$500,000, per treatment. If you bought something for that amount of money and it didn't work, you would say, "I want my money back." Why don't we have a system of guaranteed success in medicine?

Mr Gladwell: That is a good question. I blame both sides of the equation. I remember a piece I did recently for the New Yorker. I was talking about the Sovaldi® (sofosbuvir) controversy—a great drug (for the treatment of hepatitis C infection).

Dr Topol: It's amazing. The cure rate is almost 100%.

Mr Gladwell: It's a disease that costs a lot of money to treat in a chronic way. And people objected to the prices for Sovaldi.

My point was that you can't have it both ways. If you want pharma to produce first-class drugs, when they hit a home run, you have to let them charge home-run prices. At the same time, when they don't hit a home run, you have to stand up and say, "You can't charge home-run prices."

We can't make a blanket objection to expensive treatments or care of any kind. We have to say, when it is merited, that we will take out our wallets and pay; that will send the right message to people who are in research and development, and thinking about the future of medicine.

When it is not warranted, we are going to stop wasting our money. That is what I want to see—some correlation between what we pay and what we get back.

Dr Topol: I read your piece on Sovaldi and thought that it was the right way of thinking. There are a lot of drugs that are only working in 10%-20% of people and the manufacturers are charging exorbitant prices, unlike Sovaldi and other hepatitis C drugs that have remarkable efficacy. Cures are rare in medicine, right?

Mr Gladwell: I can think of many drugs, other than Sovaldi, about which I would jump up and down and be outraged about the price.

Dr Topol: Back in the 1980s, when I was involved with tissue plasminogen activator (tPA), it cost $2200, and it was on the front page of every newspaper—$2200 to save a life after a heart attack. Now it is a totally different world. It is wild.

A Background in Science Reporting

Dr Topol: You have had a lot of background in science. When you were at the Washington Post you wrote on science, and now you have been at the New Yorker for almost 20 years. How do you decide whether you are going to cover a topic like this? There are so many different areas that you could delve into. What makes you say, "I am going to write about this. I am going to use my astute observer capabilities to zoom in on this particular topic"?

Mr Gladwell: Part of it is my own shifting curiosity. Over time, I become interested in different things, and part of it is the competitive landscape of the New Yorker. I used to write a lot about medicine; then we started to run a lot of pieces by Atul Gawande, and it is very hard to be a better healthcare writer than Atul Gawande. The bar is very high for healthcare pieces right now.

Dr Topol: He is on the inside; you have an outside perspective.

Mr Gladwell: That's true. He is so good that it is intimidating. He is better than I am, and it is a part-time job for him, so I have written less about healthcare since he arrived. But the great thing about the New Yorker is, at this point in my career, they let me chose my path. I can go in almost any direction, and people aren't territorial. In a newspaper, you can't go anywhere. People have their beats and their areas. The New Yorker is wide open. It just has to be thoughtful, and that is the only criterion.

Dr Topol: Speaking for the medical community and the Medscape audience, we are hoping that you will write more. I remember the biotech piece you had in the New Yorker and many others that were very illuminating. You have a refreshing, very astute observer capability. It is great to get a view from you.

Healthcare: A Poor Storyteller

Mr Gladwell: One thing that has always motivated me in writing about healthcare is that the world of healthcare does a very bad job of storytelling about itself. It represents itself to the public very poorly. The gap between the reality of medicine and the way the public thinks about medicine is growing, not shrinking.

For example, I recently gave a talk at the California Medical Association in Los Angeles—just a group of doctors. What is so striking when you talk to ordinary, front-line doctors is how frustrated and unhappy they are in the present day with the way that their workloads have shifted, how their status in society has changed, and the way that electronic medical records (EMRs) have been conceived and pushed on them so that their own interests are last.

Dr Topol: EMRs haven't been a hit—that is for sure.

Mr Gladwell: They have not been a hit, and I don't think the public understands. For example, 90% of the public thinks that doctors would welcome that innovation and assumes that EMRs made doctors' lives easier, when, in fact, the opposite is true.

That is a classic storytelling problem. Because most electronic things have made my own life easier, I just assume that it is the same for doctors—but, in fact, it is not. Technology is always being used in a particular context, and the context of medicine is so similar to the context of banking that you can't draw an analogy from one to the other. There are countless examples of those, and where I see that kind of breakdown, I sense that there is an opportunity for a journalist.

Dr Topol: It would be great if you were willing to zoom in on it further. Storytelling is a big deal, and it isn't done enough in medicine or science. How did you get to be the storyteller that you are? Is that a quality that you are born with?

Mr Gladwell: No. It is something that I have taken very seriously. I wasn't always a good storyteller, but I have done a few things very consciously in my journalism career. One was to have a very long apprenticeship. I spent 10 years at the Washington Post learning the craft. I was not very good at all when I started, and was better when I finished, but 10 years is a long time. It was 10 years of writing four or five stories a week.

I also spent a long time studying people who I thought were better storytellers than I was and trying to figure out why.

The third thing that I did a lot of that helped was public speaking, which informs writing in a very useful way. If you can tell a story in front of a group of people, it makes the task of telling a story on the page much easier.

Dr Topol: When you are reading something, is it like you are listening to it?

Mr Gladwell: Yes, to yourself. I thought it would be the opposite—if you were a good writer, it would help you give a talk. In fact, that is not true at all. In many ways, being a good writer can frustrate your ability to give a talk to an audience. The discipline of being required to hold someone's attention in real time is an unbelievably useful skill when it comes to writing a story on a page.

Become a Brain Surgeon in 10,000 Hours?

Dr Topol: One thing you wrote, which a lot of people have reacted to, is the idea that in 10,000 hours, anyone can become a brain or heart surgeon. Could you clarify that?

Mr Gladwell: Not anyone.No single thing that I have ever written has been more routinely bastardized in the retelling.

The 10,000-hour principle is that in a wide variety of studies over many years, psychologists have looked at the question of how expertise in cognitively complex tasks is acquired. They asked the question: Given a requisite threshold of talent, how much time does it take to unlock that talent and make it real in whatever discipline you are practicing?

It doesn't refer to just "anyone." If you are looking at people who are good enough violinists to make it into a first-class music school, once we start with that school, who succeeds? The answer is those who work the hardest. It is not a random sample of people; it is the people already selected for that ability.

So I have said that in certain surgical specialties, if you start with a preselected group of intelligent people, virtually anyone in that group of preselected intelligent people who have what it takes to put in the necessary time and apply themselves, with discipline and apprenticeship, could achieve success in a long list of fields.

This is true of everything from being a good accountant or an effective surgeon to being a reasonably successful musician. I don't think that predicts who would be at the very top of the profession, but could any reasonably intelligent person who wanted to put their time and energy into it be a good pilot? Yes, absolutely.

This is not a controversial point; for many professions, the crucial variables are discipline and hard work, not some magic elixir. In fact, finding people willing to put in the discipline and hard work is the hard part. Talent is actually relatively plentiful. Discipline and hard work are actually rare, and when we search for people, what we are really searching for are discipline and hard work, and the capacity to apply oneself and continue to learn over an extended period. That is what we are looking for in any profession when we want to hire someone. We are not looking for someone who has some innate gift, because God knows whether they will make any use of it.

Dr Topol: That is a vital point for selecting doctors of the future. Today, anyone can use their prosthetic brain to look up information. The criteria have been MCAT scores and the ability to acquire and regurgitate information. We have a problem, because going forward that is not going to be such an important role of doctors—whereas we have problems with communication, compassion, and other, more humanistic features.

Do you think that it is time that we start to change the way we select who would be doctors of the future?

Mr Gladwell: Yes, absolutely, but at the same time you have to change the structure of the profession. I always use my 85-year-old mother as an example. What does my mother want from the medical profession? She uses far more of the healthcare profession than I do. Her needs are much greater than mine, as is typical of all of us. At her age, what does she want?

What she really wants is an individual physician in her life who knows her well, who listens to her, whom she trusts, and with whom she can periodically have extended conversations. That is what she wants. It matters less to her that she has access to world-class, cutting-edge technology, because she is 85.

She wants someone who can guide her through what is becoming an increasingly complicated, confusing, and terrifying period in her life. She doesn't just need someone capable of having those conversations with her. She needs a system that allows that physician to spend 25 minutes with my mother when she needs 25 minutes, which is not every time she goes. Maybe it is just twice a year, but right now we have a system where finding 25 minutes twice a year is really hard.

So we can change who we select for medicine all we want, but unless we change the nature of medical practice, it is pointless. We are just going to have brilliantly gifted doctors capable of having these kinds of discussions who are forced into a system where they have got to run the patients through an electronic treadmill.

Dr Topol: Is she up in Canada, or is she here in the United States?

Mr Gladwell: She is in Canada.

Dr Topol: Is it different there?

Mr Gladwell: I am not sure. I grew up in a small town in Ontario, and there was tremendous continuity. All of us went to the same doctor as a family for 25-30 years. That is probably true of small towns nearly everywhere. That is a function of small-town medicine, but for what we are talking about, it isn't much different. Canadian doctors face the same pressures.

Dr Topol: Here in the United States, the average visit is 10 minutes, and it is hard to stretch it out to 20-30 minutes.

An Outlier's Success

Dr Topol: You are an outlier. You have accomplished much, but might not have predicted that you would. You didn't go to graduate school. You weren't the number-one student in college, but then you have had a career that has been extraordinary. How do you account for that? Was it just hard work?

Mr Gladwell: I'm not very good at making sense of my own career. I will only say, to pick up on your point, that when I look at my own career it has made me profoundly distrustful of the practice of making predictions about people too early in their careers. It strikes me that there is a very distressing trend in the American educational system, which is this desire to make predictions, to push people into streams—or to make predictions about their outcomes earlier and earlier in their lives, which seems to be crazy.

It should be the opposite. Particularly as the kinds of professions we are training people for grow more complex, we should be putting off the moment of prediction as long as possible. We should also be allowing people to circle back into professions of any kind, later in life.

When I look at my career, it was utterly unclear until my late 20s or early 30s what I was good at, which is normal, relatively speaking. But it wasn't accepted by society, which would rather make a judgment about me much earlier.

Dr Topol: [Society wants that decision made] as a teenager, or even younger.

Mr Gladwell: It is very foolish. I have become very interested in the topic of how efficient a society is at exploiting the pool of talent available to it. That is called "capitalization" in the economic literature. For every measure you look at for capitalization rates, even in 21st-century North America, society suggests that they are very low. In other words, we are not very good at exploiting the available talent. We miss—and we are still missing—huge numbers.

I'm a distance runner. A very simple way of looking at this is to ask, what percentage of Americans are capable of running a 2:20 marathon? How efficient is the marathoning world at capturing people in the 95th percentile or above? I think we probably capture 10% of the 2:20 marathoners.

Dr Topol: It is a total mismatch of people and what they could do. We don't nurture, and we don't have a good way to bring that out in folks.

Mr Gladwell: If I had to name the greatest challenge facing our society, it would be to improve that capitalization rate. Do a better job of figuring out what people are good at, and let them do it.

Reaching the 'Tipping Point' of Medicine

Dr Topol: To pick up on another of your book titles—The Tipping Point—whenever I hear that phrase I think of you. Was that a buzzword before your book? Now everything is a tipping point. What is going on with that?

Mr Gladwell: It was in the sociology world. There was a lot of literature and discussion of tipping points, but it hadn't crossed over into the popular vernacular. I by no means invented it. I just loved the phrase whenever I ran across it in the literature and thought it deserved a wider airing.

Dr Topol: I can hardly go to a conference where at least one of the speakers isn't talking about the tipping point.

Let's get back to healthcare and medicine. It is a desperate situation. We spend $3 trillion in this country, and a lot of it is waste and unnecessary stuff—the wrong drug for a person, for example. Do you have any ideas about how to fix this mess?

Mr Gladwell: I always say that my views of medicine and healthcare change every 2 years. I have swung from one point in my life when I was convinced that everyone needed the Canadian system. Then I became convinced that that was the worst thing, and what everyone needed was something that went in exactly the opposite direction. Then I thought Canadian healthcare is good for Canadians, but probably not good for Americans. I have occupied every spot on the continuum.

At the present time, I am most encouraged by the notion thatthere ought to be, at the bottom end of healthcare—the simplest, most routine end—a cash economy. Rather than expanding insurance we ought to be restricting insurance. Let's use insurance for the things that insurance is best for, and insurance is best for catastrophic events—unexpected, big-ticket things that no one could plan for or anticipate. And for the stuff that is predictable and manageable, let's use the market to handle that, because that is what the market is good at.

I like that idea. How we get there I don't know.

Dr Topol: That's another question.

Mr Gladwell: Many people who are smarter than me look at the evolution of Obamacare at the present time and say, "There is a surprising move toward these very high-deductible plans." Although I am scarcely typical, I have opted for a very high-deductible plan for precisely this reason. Is there some way that we can subsidize and help people deal with a cash economy, and use healthcare savings accounts? There are all kinds of ideas out there, and I wonder whether at least experimentation with this might not be the right way to go. That might curb some of the worst overtreatment instincts that people have.

This is an unpalatable example, but because I run so much, I have all kinds of problems with my toenails—and I have, among other things, that fungal thing in my toes.

Dr Topol: It is hard to pronounce.

Mr Gladwell: I don't want to pronounce it, it is so gross. Whenever people look at my toes, they say "You should treat those," and the treatment is a relatively nasty antibiotic. To which I say, "Why?" It is not killing me. It doesn't hurt. The antibiotic is kind of nasty. There is no reason to treat them, other than this slightly unseemly look to my toes—which, by the way, is not that bad. It is not grotesque.

Dr Topol: It is an awfully common thing, too.

Mr Gladwell: There is a feeling that every minor imperfection that we have requires the intervention of the healthcare system.

Dr Topol: Especially in America.

Mr Gladwell: Yes, in America. If my own money was on the line, I would think twice about that. That is what we would get to. We wouldn't run to the doctor with every minor ear infection or cold and sniffle. We need to have an injection of the disciplining effect of common sense, and at the bottom end, that would not be a bad thing.

Dr Topol: Yes, and we may have ways to do that with people who are connected through their phones and getting information about themselves and all sorts of decision support. You are bringing up the threshold of actionability—do you really need to do something when it is not a bother? It is not causing any trouble.

Mr Gladwell: I have seen that with my own parents. My father went through a surgery that, in his 80s, was a mistake. It was an elective surgery, but it was traumatic and we shouldn't have done it. Maybe the system made it too easy for us to do what was, in retrospect, a mistake. When something isn't crucial, you need to spend some time and think about whether you really want to do it.

Dr Topol: Too often, that is not the case.

Do you have any plans after David and Goliath, the support of the underdogs? Do you have a sixth book in mind?

Mr Gladwell: I do. I have been thinking about things. The idea that I keep coming back to (and it applies a lot to medicine) is, when are the predictions that we make about people useful and when are they problematic? When are we better off with a very clear set of nonspecific rules and guidelines and when are we better off focusing and specifying the way we act or treat based on the individual in front of us? We want things to be highly individualized, and sometimes it is a terrible mistake to do that. I would like to clarify that.

It is at the root of every question in the legal system, and in medicine. We can go in the direction of individualized treatment, but that has tremendous cost implications. We need to think hard about when we want to do it, and I don't know whether, as a society, we have developed a methodology for working through when we want to do it and when we don't.

Dr Topol: We certainly hope that you get into that, because that is one hot topic and it would be great to get your insight.

It has been a delightful conversation, Malcolm. Thanks so much for joining us. We touched on so many interesting topics and I appreciate your willingness to share your views. They are always insightful and often humorous, too, so thank you.

Thanks to all of you for joining us on Medscape and getting the chance to meet one of the most interesting people I have ever known: Malcolm Gladwell.