By Robert Pearl, MD | | September 22, 2015

Malcolm Gladwell hasn’t written much about American health care. But that doesn’t mean he hasn’t been thinking about it. And it sure hasn’t stopped many of his powerful ideas like “tipping point,” “outlier” and “blink” from gaining entry into the national health care debate.

In his most recent book, “David and Goliath,” Gladwell reshaped our perspectives on the underdog and highlighted our tendency to over-value certain strengths. In the health care world, this concept helped expand our understanding of the role of mobile devices and big data in health care.

As our nation confronts the challenges of American health care, there’s a lot we can learn from Gladwell. I recently met with him at his house for two hours on a cold, clear day in lower Manhattan. We talked about the Affordable Care Act and what physicians can do better in providing health care. We spoke about Canadian health care and America’s malpractice system.

I expected him to offer insightful and novel views on these topics. He did not disappoint.

On The Affordable Care Act

“I have profoundly mixed feelings about the Affordable Care Act,” Gladwell started. “What I love about it is its impulse. It attempts to deal with this intractable problem in American health care life, which is that a significant portion of the population does not have access to quality medical care.”

While praising the Affordable Care Act for insuring those in need of coverage, Gladwell expressed sincere concerns about whether this approach could truly solve the challenges America faces.

“Part of me thinks that innovation, real innovation in health care delivery, needs to happen from the bottom to the top,” he said. “What I don’t know is whether this system encourages that kind of bottom-up innovation or discourages it.”

Gladwell may be uncertain about the system’s ability to encourage bottom-up innovation, but we know one thing’s for sure: our current system rewards volume through fee-for-service payment models. And until we move to a system that focuses on value, we won’t enable the kind of bottom-up innovation Gladwell talks about.

The Affordable Care Act takes us one step in the right direction. But physician leadership will be essential to effectively drive the innovation needed to transform the system.

On Nudging American Health Care

“A lot of the things we identify as problematic with the delivery of care are simply features of the irrationality of the system itself,” Gladwell lamented.

He cautioned that we have become too dependent on health insurance to pay for predictable medical problems. Rather, he said, the purpose of insurance should be to pay for the unexpected. In his mind, the current insurance system provides very few incentives for patients to live healthier lives or for physicians to encourage healthy living.

“We aren’t, as human beings, very good at acting in our best interest,” he said. And noted that an appropriate role for government or other third parties is “to make it easier for us to act in our best interest.”

Gladwell is a fan of change happening through many smaller, incremental improvements. He credits Richard Thaler and Cass Sunstein’s book “Nudge” for this line of thinking. He used the auto industry as an example:

“In the ‘60s, they started nudging car makers in the direction of safety,” he recalled. First, “You’ve got to equip all cars with seatbelts.” Then, “In the ‘70s, we started setting standards for fuel economy.” Finally, “The automobile industry took those (nudges) and used them to create airbags and develop hybrids.”

“The automobile is a great example of how the health care system can work very well. A combination of aggressive and smart regulation and a highly competitive marketplace has combined to improve – not perfect, but improve – the quality of decisions made by consumers.”

Applying this concept to health, Gladwell questioned why governments and private organizations couldn’t find more opportunities to encourage healthier behaviors.

“When I go to my health club and it’s in the basement, you have to take the elevator down. And this drives me crazy. Why can’t there be a stairway? At least make it as easy to exercise as it is to not exercise. It’s in society’s interest for me to take the stairs.”

Ultimately, Gladwell believes human beings need a little help.

“As a society we have to push them, nudge them, in the right direction.”

And just as Gladwell applied this principle to patients, I believe it also applies to how physicians provide care to their patients.

Meaningful Use regulations, which provide financial incentives to health care providers for the “meaningful use” of certified electronic health record (EHR) technology, will nudge physicians to incorporate and use 21st century technology. Increased payments for Five Star Medicare Advantage plans will nudge health care organizations toward a greater focus on prevention. Reduced payments for hospitals responsible for patient complications will nudge them away from medical errors. And incentives for the creation of Accountable Care Organizations will nudge physicians and hospitals to embrace greater collaboration, coordination and integration of medical practices and clinical care.

While these changes themselves will not eliminate the problems of today’s health care system, they will nudge the industry in the right direction. And the result will be better care for patients.

On American Vs. Canadian Health Care

While it’s tempting to compare the failures and successes of U.S. health care with other nations, Gladwell warns that underlying societal differences make those comparisons difficult.

“There are many things that are exceptional about American health care but there are two things to consider above all else,” he said. “One of them gets a lot of attention and one doesn’t get enough at all.”

A lot of attention, according to Gladwell: U.S. technology. Not enough: America’s social dynamics.

In terms of U.S. technology, he pointed out the complexity of evaluating its impact. On one hand, Gladwell said, technology has resulted in significant advances. On the other hand, technology has created an enormous economic burden.

“If you are the technology pioneer, you’re going to generate higher costs than those that follow. Those that follow have many advantages. They can sit back and cherry pick what they like. They avoid the high cost of technology that goes in to prescription drug development. ”

“That’s a case where the

[U.S.] health care system has gained from medical advances but had to carry the economic burden for much of the world.”

He posited that technology may be a net positive once we take all parts of the economy into consideration, but that the calculation is complex. And that’s where the second factor, the one that doesn’t get enough attention, comes into play.

“Our health care system is part of the very, very peculiar social dynamics of this country, which is that we are one of the most, if not the most violent of the developed countries,” he said. “And the consequences of that violence for the health care system are considerable. For example, compared to most countries, the economic consequences of the United States caring for veterans are extraordinary and its impact on overall health care costs in America is considerable.”

He noted that wars in Korea, Vietnam, Afghanistan or Iraq – along with a large standing army – placed a considerable financial burden on the U.S. health care system. In addition, he said poverty and violence in America have increased the nation’s health care challenges.

“An interesting thing about Canada is that Canada doesn’t have the inner city problem that America does,” he said. “It does not have a very large and entrenched underclass. That’s a huge burden on the system. So, America has some distinctive features that impact health care spending in a very considerable way. When we look at the cost of American health care and blame the health care system for it, that’s not entirely fair. A lot of it is a function of who we are as a nation. We’re a country that runs up a big health care tab. We’re a country that has yet to figure out how to address the social challenges we face. As a result, the health care system carries much of the burden.”

That’s why, Gladwell said, “I’ve never trusted cross-national comparisons of health care spending. It’s just not useful until you’ve normalized these differences.”

There’s no doubt in my mind that we have much to learn from nations beyond our borders. Providing access to health care for all residents – and access to life-saving medical services that won’t bankrupt patients – is worth further consideration.

But I agree with Gladwell that technological, social, cultural, financial, legislative and other factors make direct comparisons difficult.

On America’s Malpractice System

Gladwell described the current malpractice tort system as poorly designed for the purpose it should serve. The function of an effective malpractice system, in his mind, should be to compensate individuals and to address the underlying causes so that we can reduce recurrence. The current system does none of this. He pointed out that most problems in medical care delivery happen as a result of failed systems, not individual errors.

“The fact that only a small percentage of medical errors are dealt with in the malpractice system suggests that it’s not a system,” he said. “It deals in an incredibly inefficient way with a small percentage of the actual errors and in such a way that it does not make the performance of the overall system better. It’s not addressing why the error was made in the first place.”

The solution? According to Gladwell, we should, “Compensate more of those that suffer from errors because the system doesn’t do that now. Make it a primary motivation to reduce the source of the error. That’s what a system, a proper malpractice system, looks like. And right now our system doesn’t look like that.”

Often, we as physicians are blamed individually every time something goes wrong in medicine. But rarely is any one individual responsible. That’s why many physicians feel forced to practice defensive medicine: to minimize the risk of financial and reputation damage. The result is added cost without improved outcomes – and on occasion, even greater patient harm.

But given today’s malpractice system, it’s hard to convince physicians to behave differently. And who can blame them? If we want to encourage system-wide improvement and address wasteful spending, we first must redesign the malpractice system, moving to one that focuses on care improvement, not individual blame.

On Government Regulations

Gladwell offered a provocative thought here, that parts of American health care may have way too much regulation and not enough wisdom, compassion and judgment. He used nursing-home care as an example.

“With nursing-home care we have a system which is heavily regulated right down to the specifics of every minor thing you do and at the same time the quality’s not good,” he said.

He pointed to one study in Australia. The country shifted away from stringent nursing-home regulations toward greater training and reliance on the judgment of nursing-home workers. As a result, he said, the quality of care improved.

“In an environment that’s about the quality of human interaction, it’s not appropriate to have 10 volumes of incredibly specific regulations,” he said. “What you want to do is get a system where people feel involved in providing important levels of human comfort.”

At the same time, Gladwell was firm that strict and detailed regulation remains essential in certain areas.

“If the issue is the manufacturer of pharmaceuticals, I’m all about the twenty volumes of regulations. I don’t want people coming in having a touchy-feely conversation. No, I want every single factory investigated and inspected on a regular basis because the consequences of failure here are enormous and you need rigorous regulation, not individual discretion.”

Gladwell’s focus on the human element in the midst of a challenging and expanding regulatory environment was refreshing. Yes, some aspects of care require a clearly defined processes to avoid medical error and improve quality outcomes. But when restrictions dominate how care is delivered then compassion and personal relationships erode. Unfortunately, that can lead to compromised medical care and unnecessary human suffering.

On End-Of-Life Care

Gladwell provided a balanced perspective on the importance of both a rules-based and an individualized approach to patient care during this time of acceptance and choice. He believes in an approach that honors dignity:

“Helping people live their lives with dignity means very, very different things at different stages of their life. If I’m 18 and I’m in a car accident, that means picking me up with a helicopter and giving me access to the greatest trauma care known to man. If I’m a soldier in Afghanistan, that means get me out of there to the best medical facility in the world. And if I’m a 40-year-old woman with breast cancer, it means providing access to the highest quality care imaginable.

“But if I’m an 85-year-old bedridden person with Alzheimer’s, that means giving me nurses who are motivated and compassionate. It means allowing me to avoid aggressive and futile interventions. Maybe it’s just helping the health care system understand that there are different ways to provide people dignity.”

As much as half of health care spending is estimated to be spent in the last year of life. Gladwell’s model would help people maximize their health throughout their life.

Surprise Twist Leaves Us Wanting More

As we began to wrap up our conversation, I asked him what else he would like me to cover in my blog. His answer surprised me. Next week’s article will focus on his request.

This article originally appeared on Dr. Pearl’s column on