5 thoughts on healthcare from best-selling author Malcolm Gladwell

Widely known for his nonfiction books including The Tipping Point and What the Dog Saw, journalist and best-selling author Malcolm Gladwell is also a staff writer for the New Yorker, often writing on science and healthcare.

Recently, Eric Topol, MD, director of the Scripps Translational Science Institute in La Jolla, Calif., and editor-in-chief of Medscape, sat down with Mr. Gladwell to discuss the field of medicine.

Here are five key thoughts Mr. Gladwell shared during their conversation.

On the high prices for pharmaceuticals: "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."

On the misrepresentation of physicians' relationship with EHRs: "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.

[EMRs] have not been a hit, and I don't think the public understands. For example, 90 percent 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."

On becoming a surgeon in 10,000 hours: "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?

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."

On needing to change the practice of medicine: "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?

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."

On healthcare's 'Tipping Point' and reducing waste: " At the present time, I am most encouraged by the notion that there 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."

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