Malcolm Gladwell on Fixing the US Healthcare Mess

hello this is Eric Topol editor-in-chief of Medscape and I'm really 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's really written a fair amount on science and healthcare and so we'll had to have the discussion we've been getting some of those interesting people in the world of medicine and sometimes it's best to get outside medicine welcome so welcome thank you I thought we could start off with something that was pretty funny very recently which was I know you're on Twitter but and you have like a few hundred thousand followers but you don't tweet too often but recently you did and it was about this whole John Paulson 400 million dollar donation to Harvard yeah and you were hilarious with it can you tell us a little bit about that well I well I like I do I rarely tweet and I I didn't imagine that these tweets would have the impact they did I forgot that I had that that anyone was even reading my Twitter I just was in the back of a cabinet we just was struck by the absurdity of very wealthy very very intelligent wealthy man who would think that that was a good use of his money to give 400 million to the richest educational institution in the history of the planet you know someone who spends his life thinking about what a good return on investment is that's not a good return on investment and I think it's appropriate to hold wealthy people who are donating tax-deductible dollars to charitable causes it's important to hold them accountable for their choices and to encourage them to make good choices so that was what we were so funny about it you had what is it John Paulson schools of financial engineering yeah you all get errors don't step up horrible sue be down to its last 30 billion I mean it was really clever I mean it was I was surely struck by it but have you had any backlash from it very little I mean from other billionaires were but mostly witches billionaires who objected I don't think is any I don't think there is sending great mystery in America right now that there is a strong perception that our dollars are being of all kinds are being misallocated you know we're spending resources in the wrong places and I I think that's gone from a kind of Rumble to a roar and people have kind of had it you know it's there are plenty of extraordinarily worthy you know state institutions around this country who are desperate for word lots of talented people are you know either learning or teaching or researching who are desperate for money who could do extraordinary things and forty million dollars yeah you know and there's a just a sense of inequity I think in America right now correctly yeah well that that's a good segue to American healthcare in medicine and you know there's all these new drugs that cost a hundred thousand or even up to four or five hundred thousand for treatment and the question would be is if you bought something for that magnitude of money you would say it doesn't work I want my money back why why don't we have a system of guaranteed to succeed what do you think about that oh that's a good question you know I I blame both both sides of the equation so I remember a piece I did recently the New Yorker I was talking about the controversy about sovaldi yeah you know a drug that is actually a great drug oh it's amazin amazing cure rate is almost 100% on a disease that cause a lot of money to treat in a chronic way and people objected to the price of sovaldi and my point was you can have it both ways if you want Pharma to produce first-class drugs you've got to let them when they hit a home run you gotta let them charge homerun prices but at the same time when they don't hit a home run you got to stand up and say you can't charge homerun prices so we can't just be have a blanket objection to expensive treatments or expensive care of any kind we have to say where it is merited we will take out our wallets and pay and that will send the right message to the two people who are in R&D and thinking about the future of Medicine where it's not warranted we're going to stop wasting our money that's what I want to see is some correlation between between what we pay and what we get back yeah knowing I saw your piece on so loud and I thought that really is the right thinking and that is there are a lot of these drugs that are only working in 10 or 20% maximum of people and they're just exorbitant prices unlike Salvati which and other Hep C drugs new ones they have remarkable efficacy I mean I ask you are so rare in medicine right I know it's it's odd that that would become I would think that would have been the last drug we would I can think of so many other drugs I would I would get jump up and down and be outraged about their price about than then sovaldi yeah well I remember back in the 80s when I was involved with TPA I remember back in the eighties in Europe poverty $2,200 and it was on the front page of every newspaper 900 one time to save a life and a heart attack yeah and now it's a totally different world as well yeah now we add two zeros yeah that's just just amazing so you have had a lot of background in I know where you were when you're at the Washington Post you wrote on science and when you pick your stories in The New Yorker where almost 20 years of New York or now right how do you pick whether you're going to cover something like this or you have so many different areas that you can delve into how what is the thing that makes you say I'm going into this I'm going to use my astute observer capabilities to zoom in on this particular topic well I mean it's um part of it is what my own kind of shifting curiosity so over time I just am interested in different things and part of it is the kind of competitive landscape of The New Yorker so I used to read a lot about medicine and then we hired we started to run a lot of pieces by Atul Gawande and it's very very hard to be a better health care better than talk money so I've kind of like the bar is really really high real wood is really he's in the inside and yet it's so anyway but he is so good that it's sort of intimidating that you know I feel like he's better than I am and it's a part time job for him so it's a a little I've written less about health care since he arrived but no it's really a kind of it's the great thing about the New Yorker is at this point in my career they'll they'll literally run anything I mean I can go in almost any direction and people aren't territorial about in a newspaper you can't go anywhere two people have their beats in their areas The New Yorker sort of wide open it just has to be thoughtful I think and that's the only well I think speaking for the medical community and the mid skateboarding's we're hoping you will write more I mean I still remember the treatment but the biotech piece you had a New Yorker and so many others that real or illuminating and I think you have this refreshing this astute observer capability that it's great to get at view from you well I you know I want to think one of the things that has always motivated me in writing about healthcare is I think people the world of health care does a very very bad job of storytelling about itself it represents itself to the public very poorly I think that gap between the way the reality of medicine and the way the public thinks about medicine is growing not shrinking so for example I recently gave a talk at 2:00 at the California Medical Association in LA just a group a group of doctors you know what's you know this was so striking when you talk to sort of ordinary frontline doctors is how frustrated and unhappy they are mmm in the present day we the way that their workloads have shifted their status and society has changed the way that things like electronic medical records have been conceived and pushed on them in a way that seems to be seems to put their own interests last they haven't been a hit that's for sure I've been a hit and I don't think the public understands most what's bizarre about to take medical records electronic medical records as an example 90% of the public thinks doctors would welcome that innovation and would assume that they made doctors lives easier right when in fact it's the opposite is and there's a kind of that's a classic storytelling problem you know because in my life most things electronic had made my life easier I just assumed it was the same for doctors but in fact no I misunderstood sort of the context in which the technology is always being is always being used in a particular context and the context of medicine is so similar than the context of banking that you can't draw an analogy from one to the other right and I think that's a that's a classic storytelling breakdown oh yeah and as there are countless examples of those and where I see that kind of breakdown I sense there's an opportunity for a journalist yeah well I think that would be a great if you would be willing to zoom in on it further I think it's a lead-in for something from your perspective very interesting but storytelling is a big deal and it isn't enough in medicine or science and how did you get to be the storyteller that you are I mean I think that's something that is a quality that is is it isn't just it you're born with right no I mean it's something I've taken very seriously I don't think I was always a good storyteller but I very consciously I did two things in my journalism career one is I had a very very long apprenticeship you know I spent ten years of the Washington Post really learning the craft was not very good at all when I started and was better when I finished but ten years is a long time of 10 years of writing four or five stories a week and and also spent a long time studying people who I thought were better storytellers than I was and trying to figure out and the third thing that I did a lot of that has helped is I found that public speaking in forms writing in a very useful way that if you can tell a story in front of a group of people you can learn how to do that it makes the task of telling a story on the page much easier so that when you're reading is like you're listening to to yourself yeah I thought it would be the opposite yeah that if you were a good writer that would help you give a talk in fact that's not true at all in fact in many ways being a good writer can frustrate your ability to give a talk towards audience but it is the opposite it is 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 the page yeah well now one of the things that you had written at one point which a lot of people have reacted to is this whole 10,000 hour and that anybody to become a brain surgeon or a heart surgeon or whatever and yeah not anyone I write people have always at that to clarify that would you that's great there's been no single thing I've ever met has been more routinely kind of bastardized and in the retelling the 10,000 hour principle says that in in a wide variety of studies over many years psychologists have looked at this question of how his expertise in in cognitively complex tasks acquired and what they have said is that given a certain amount a requisite threshold of talent how much time does it take to unlock that talent and to make it real in whatever discipline you're practicing so it's not any one you're going to start with so if you're looking at people who are good enough violinists to make it into a first-class music school right once we start with that pool who succeeds and the answer is those who work hardest it's not a random sample of people it's a people already selected for that so I have said that I think that in certain surgical specialties that if you start with a pre-selected group of intelligent people the the virtually any number of any any one of those of that group of pre-selected intelligent people who have what it takes to put in the nest every time and apply themselves and discipline and apprenticeship and what-have-you can achieve success in a field like and I could list a long list of fields sure I think this is true of everything from being a good accountant to being an effective surgeon to being a a reasonably successful musician to being I mean I could go on I don't think that's true that predicts who would be at the very top of the profession but can I be could any reasonably intelligent person who wanted to put their time energy into it be a good pilot yes absolutely and you know like I said we could make a long list of these yeah what I'm trying to say and this is not a controversial point which is that the for many professions the the crucial variable is discipline and hard work not some magic elixir and in fact finding people willing to put in the discipline and hard work is the hard part right right talent is actually relatively plentiful discipline and hard work are actually rare and that when we search for people what we're really searching for is that is discipline hard work the capacity to apply yourself and continue to learn over an extended period of time that's what we're looking for when we in any profession when we try to hire we're not looking for someone who has 7 a gift because God knows whether they'll make it well you know that's a very vital point you're making and now selecting doctors of the future because today anyone can use their prosthetic brain to look up information and so the criteria for these MCATs and selecting doctors has been you know abilities to acquire and regurgitate information but obviously we have a problem because going in forward that's not going to be such an important role of doctors whereas we have problems with communication compassion and these other you know much more humanistic features so do you think that it's time that we start to change the way we select out who would be doctors of the future yeah and I think solutely but I think you have to do that and at the same time change the structure of the profession so you can't so right now we have I always use my mother as an example so I have an 85 year old mother what does my mother want from the medical profession she uses far more the medical of the healthcare profession than I do right her needs are much greater than mine as that's typical of all of us I think at her 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 who she trusts and who can she can periodically have extended conversations with right that's what she wants she it matters less to her that she has access to world-class cutting-edge technology because she's 85 yeah yeah sure what she really wants is someone who just can guide her through what is becoming an increasingly complicated confusing and terrifying period in her life so she needs she doesn't need just need someone capable of having those kinds of conversations with her she is 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 I mean maybe it's just twice a year but right now we have a system where finding 25 minutes twelve-year is really really hard you got it right so you can't we can change the structure of who we select from in us and all we want but unless we change the nature of medical practice it's pointless which we're just going to have brilliantly gifted doctors capable of having these kinds of discussions who are forced into a system where they got to run oh your nation seemed like not as she up in Canada or she here in the US and Canada so is it different you think they're uh it's it's different in many ways is it different in the burbs yes for her yeah I'm I'm not sure I know that she had we lived in a small town in Ontario we covered in sports in Ontario and there was tremendous continuity in our health you know we all of us went to the same doctor as a family for 30 years you know in five years now I think that's probably true of small towns nearly anywhere that's a function of small-town medicine as much as it is but I don't know I don't think that in the respect that we're talking about it's much different I think Canadian doctors face the same pressure - yeah well here in the US the average visit is 10 minutes and it's hard to get as you say stretch it out to 20 30 whatever so absolutely right now you are an outlier that's a to use your book title because you have accomplished so much but it might not have predicted that right you didn't go on to grad school you weren't the best you wanted to college number one student but then you turn you have had a career that's been extraordinary how do you account for that was that just hard work or what do you think very good at making sense of my own career I will 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's this very distressing trend in the American educational system which is this desire to make predictions to push people into streams or make predictions about their outcomes earlier and earlier in their lives which seems to be crazy it should be the opposite that particularly as the 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 hmm and we should also be allowing people to circle back into professions later later in life of any kind yeah so I think you know I look at my I look when I look at my career I was he was utterly unclear until my late 20s or early 30s what I was good at which is I think is normal well to be sure sure not but not not accepted by society would rather I made my but we matter has made a judgment about me much early sure teen teenager or younger I think it's really foolish there's a lot of I've gotten really interested in this topic of how efficient a society is at exploding the kind of pool of talent available to it and every measure you look that's called capitalization in the economic literature every measure you look at capitalization rates even in twenty-first century North American society suggests that they're very low in other words we are not very good at successfully exploiting the available talent we miss we're still missing huge numbers of yeah so I you know I'm a big runner and you just you can ask the question I'm a distance runner a good very simple way of looking at it is what percentage of Americans capable of running a let's say at 220 marathon run or 220 marathon like how good how how efficient is the marathon in world at capturing people in the 95th percentile or above and I would say the answer is I think we probably capture 10% of the 220 marathoners yeah I don't think it's much different in a whole variety it was total mismatch of people and what they could do it's we don't we don't nurture or we don't have a good way to to bring that out and focusin know I think it's I think I think that is to me if I had to name what is the the greatest challenge facing our society it is to improve that capitalization rate to do a better job of figuring out what what people are good at on letting them do that yeah now to bridge to pick up on another title of your book of books five of them tipping point that were that phrase whenever I hear it I think of Chevelle so was that a real buzz word before your book or is that now everything is a tipping point what's going on with that it was in the sociology world there was a lot of literature on tipping points and discussion of tipping points but it hadn't sort of crossed over into the popular vernacular oh my gosh but I I know means indented it I know I understand the phrase whenever I ran across it in in the literature and thought it deserved a wider air I mean I can hardly go to a conference where at least one of the speakers isn't talking about the tipping point now yeah I pretty wild now let's get back to the healthcare medicine scene it's it's kind of a desperate situation we've got three trillion dollars in this country a lot of it is waste unnecessary stuff a lot of it's mismatch of drug for the wrong person or you know all sorts of things you have any ideas of how to fix this mess well it's funny I you know one of the things I will say about my views about medicine and healthcare is that they change every two years so I go from I've swung from being one point in my life I was convinced what everyone needed was the Canadian system then I became convinced that no no that was the worst thing at what everyone needed was something that went in exactly the opposite direction then I was like well Canadian healthcare is good for Canadians were probably not good for Americans I've you know I've taken I've occupied every spot on the continuum at the present time I'm most encouraged by the notion that there ought to be at the bottom and of health care at the simplest most routine end a cash economy that what we ought to be doing is not expanding insurance but restricting insurance let's use insurance for the things that insurance is best at and insurance is best at catastrophic events unexpected big-ticket things that you have no no one could plan for or anticipate or and let's turn the stuff that is that is in predictable and is manageable let's just use the market to handle that because that's what the markets good at I like that idea how we get there I yeah that's another question again but I I said I should there are many people smarter than me who look at the evolution of Obamacare at the present time and say you know people all going for there's a surprising move towards these very very high deductible plans I myself I'm scarcely typical but I have opted for a very very high deductible plan for precisely this reason that I you know the the everyday stuff I just rather and if you know is there some way that we can subsidize and help people deal with the cash economy use healthcare savings accounts use there's all kinds of ideas on there and I wonder whether at least experimentation with that might not be the right way to go and I think that might curb some of the worst instincts over treatment instincts that people have you know so for example this is a a a a a a slightly unpalatable example but because I run so much I have all kinds of problems with my toenails and I have among other things um that fungal thing in my toe yeah sure it's it's hard to pronounce yeah I don't want to protect some gross and okay whenever people look my toes they say you should treat those and you treat it with a relatively nasty antibiotic yeah to which I say why right it's not killing me sure it doesn't hurt the antibiotics kind of nasty it's there's just no other than a this slightly unseemly look to my toes you know which by the way it's not that bad it's not like the testicle it's an awfully common thing too awfully common I mean do I have to I might you know there is a kind of feeling that every minor imperfection that we have requires the intervention of the healthcare system well especially Hurka yeah in America if my own money was on the line I would think twice about that right and I think that's what we would get to we would just be you know maybe we wouldn't run to the doctor with every minor ear infection or cold and sniffle and we would and I think that's what we need to have the injection of some kind of the disciplining effect commonsense at the bottom end would not be a bad thing yeah we may have ways to do that with people that are connected through their phones and getting them information about themselves and all sorts of other kind of decision support yeah especially as you're bringing up this kind of threshold of actionability and do you really need to do something when it's really not a bother it's not causing any trouble whatsoever yes I have seen that with my own parents my father particular has went through a surgery which in his 80s which I think was a mistake it was it was not a it was an elective surgery but it was traumatic and it shouldn't that we should have done it and and I think maybe the fact that the system made it too easy for us to do that kind of thing was in retrospect a mistake it should have been the stuff that isn't crucial you need to spend some time and think about whether you really want to do it ya know I think too often that's not the case so you're absolutely right well you've you have any plans for after David and Goliath on the support of the underdogs do you have a sixth book in mind are you in the middle of something I've been thinking about things I'm really the idea that I keep coming back to is and it applies a lot to medicine which is when our predictions that we make about people useful and when are they problematic when are we better off with just a kind of very clear set of nonspecific rules and guidelines and when are we better off really focusing and specifying the way we act or treat based on the individual in front of us and sometimes we want things to be highly individualized and sometimes I think it's a terrible mistake to do that and I'd like to kind of try and clarify that would be great the I don't think I can do it I think is one of the hardest questions but I think it's and it's important stuff really important the root of every you know questions in the legal system the Russians in Madison questions in you know if you even think about something as simple as you know we can go in the direction of individualized treatment for various kinds of but that has at least in a short-term caused implications tremendous cost implications right so you really to think hard about when you want to do it and I don't know whether as a society we have a kind of we've developed a methodology for working through when we want to do and when we don't well we certainly hope that you get into that because that is one hot topic and great to get your insight so it's been a delightful conversation Malcolm thanks so much for joining us and we touched on so many really interesting things and really appreciate your your willingness to share your views they're always insightful and often humorous too so thank you and thanks to all of you for joining us on Medscape getting a chance to meet one of the interesting most interesting people who I've ever known Malcolm Gladwell and will look forward to having you join subsequent interviews thank you you

Channel: Medscape

Views: 82,244

Rating: 4.7823129 out of 5

Keywords: Medscape, concierge medical practice, health care reform, health care spending, pharma, health technology, patient care, drug pricing, health insurance, affordable care act, Malcolm Gladwell, Eric Topol

Id: rMA3HoW0j0Y

Length: 29min 57sec (1797 seconds)

Published: Tue Jul 14 2015