How Malcolm Gladwell, Atul Gawande And Others Inspired Me This Year

In the course of writing this column for Forbes, I have had the opportunity to talk with patients, physicians, authors, academics and business leaders. With 2015 drawing to a close, I want to highlight some of the lessons I have learned from six internationally recognized thought leaders. Each has greatly influenced my thinking and writing.
 
Malcolm Gladwell: Journalist and Author of “The Tipping Point” and other bestsellers

No one I know is as skilled as Malcolm at drawing on diverse experiences and observations to help others see patterns they might otherwise not recognize. His books are a joy to read.

When I interviewed him at his home in New York City, I asked him what he would suggest I write about for Forbes. His response was immediate and straightforward: “Help people understand what it is really like to be a physician.”  The resulting column was read by more than a half million people.

At the time his answer, and the overwhelming response, surprised me. But in retrospect, I understand.

Most people have little or no idea what life is like – really like, as he put it – for practicing physicians. The bond between patient and physician is among the most sacred in society. Doctors are given the privilege of asking the most personal of questions, examining the human body, and penetrating the skin with needles and knives. In return, patients expect expertise and a commitment to putting their well-being ahead of the doctor's self- interest.

Malcolm questioned why people today would want to become physicians, given how much time they will be required to spend completing paperwork and navigating complex coding requirements. How disappointing  it must be to spend ten years in medical school and residency only to wind up “running a claims-processing operation for insurance companies,” especially when the process frustrates patients as much as it does their care providers.

On one hand, the clinical advances in disease prevention, diagnostic accuracy and effective therapeutic interventions in the 21st century have been remarkable, and are incredibly fulfilling for physicians today. As a result doctors routinely offer diagnostic testing and advanced treatment options never before imagined. But on the other hand, as Malcolm so astutely pointed out, the advances in how health care is organized, delivered and reimbursed have lagged.  

Our conversation inspired me to write a three-part series on the experience of being a physician. It also energized me to redouble my efforts to help move American medicine from a fee-for- service, pay-for-volume cottage industry to a fully-integrated, technologically-supported, prospective pay-for-value system.  Like Malcolm, I know we can do much better on behalf of both patients and physicians, and the overwhelmingly positive response to the article makes me optimistic we will.

Dr. Atul Gawande: Surgeon and Author, most recently of “Being Mortal”

I have admired Atul's writing ever since reading his first book Complications: A Surgeon's Notes on an Imperfect Science, his personal account of his life as a surgeon.  He has since published on a variety of complex medical and social issues.

His themes resonate with me as a fellow physician. Preventing illness is undervalued in America today, and that needs to change. Avoiding medical error and maximizing patient safety in our hospitals will simultaneously improve quality and reduce costs. Telling patients the truth at the end of their lives, even when it is difficult, is the right thing to do.

Atul and I participated on a panel at Stanford Medical School this year. He told moving stories about the difficulties his father experienced near the end of his life, and, listening to him, I reflected on the problems I witnessed during the final days of my parents' lives. As physicians we have the ability to cure, but we also have the power to do more harm than good, particularly in the vulnerable period at the end of a patient's life.

When physicians educate patients about the options that exist, patients can make the best choices for themselves. That’s far better than when doctors try to do it for them. All too often, as physicians, we focus on acute intervention and complex treatment, rather than on prevention, life style changes and less risky solutions.  We confuse "doing more" with "doing our best" to optimize the quality of people's lives.  
 
Telling patients the truth about what is likely to happen is fundamental to informed consent. Given the recent decision by Medicare to begin to reimburse the time it takes to have these conversations, and the commitment of some of the nation's largest medical societies to educate doctors on what doesn't work, I am hopeful  physicians and patients will engage in more honest and open conversations in the future.

Chip Heath: Professor at the Stanford Graduate School of Business and co-author of “Decisive: How To Make Better Decisions In Life And Work”

Chip is an expert in human behavior. The book Switch, co-authored with his brother Dan, is the most powerful treatise I have read on how change happens, and the process by which leaders can make the greatest difference. When I interviewed him, he pointed out that people often reach decisions that are flawed because they’re overconfident in their ability to make the right choice. And that doctors are no exception in this regard. He cited studies suggesting that when physicians make an initial diagnosis that is incorrect, they frequently justify their conclusion by ignoring data that contradicts their initial determination.

In talking with Chip, I thought about the broad variations in how physicians treat medical problems. When doctors see patients with similar headache type symptoms, their referral rates to neurology can vary as much as three to five times.  Similar differences are also evident in how often doctors recommend surgery for back pain and prescribe additional courses of chemotherapy with its associated complications for patients with incurable cancers.  According to the Dartmouth Atlas, costs of treatment vary tremendously without outcomes being any better -- and often worse for patients who receive more care.

Doctors want to believe their personal approach is the best, and defend their actions by defining the practice of medicine as an art. And this has some truth to it.  But today, medical practice is far more a science than an art.  And when solid science supports a specific intervention or a particular course of therapy, individual variations tend to compromise quality and increase cost. Best practices often are derided by some physicians as "cookbook medicine," My conversation with Chip reinforced my belief that when "cookbooks" are written by the world's best chefs and followed closely, the results are consistently exceptional and world-class.  
 
Clayton Christensen: Harvard Business School professor and author of the “The Innovator’s Dilemma”

Clay introduced the concept of "Disruptive Innovation" to the business world. He pointed out how technology and systems tend over time to become too complex and expensive, and are ultimately replaced by simpler, less costly solutions. When I asked him how he believed health care could improve, he proposed that fixing the health care system might require an undemocratic, even autocratic approach.

Clay said the key to improving health care for Americans will be leaders who are strong and know how to drive change. His reason is that the main players in American medicine – private-practice doctors, hospital executives, and insurance companies – will resist approaches that cut into their incomes, even when the changes would benefit patients. He said his research shows that unless an organization can achieve consensus on what it wants and how to get it – a rare event – the best path forward is forceful leadership.

His insights reinforced for me the importance of physician leadership. Some solutions can be imposed, but physicians are most likely to follow colleagues they know and respect clinically, as opposed to hospital administrators and health plan executives. But for physicians to be strong leaders, they need something that in the United States is often lacking: education and training to develop their leadership skills and capabilities.  In examining why the National Committee for Quality Assurance often ranks programs with large multi-specialty medical groups as five-star,  I’ve noticed this consistent characteristic: strong and effective physician leadership.  

John Chambers: CEO of Cisco

John led Cisco as its CEO for nearly two decades, making it one of the most successful businesses in the world. Through his leadership, Cisco created products to connect people in ways increasingly convenient and reliable. When I interviewed him, he pointed out that if the health care system is to reach its potential, it will have to take full advantage of the most modern communication and information technology available.

Currently the various participants in the health care industry tend to operate in silos, John told me. But success will depend on whether health care leaders will provide individuals with broad connectivity across those silos, linking devices on people's bodies and in their homes with the physicians and hospitals caring for them. Increasingly, patients and health care professionals will deploy video and mobile devices to stay in touch with each other and collaborate, helping patients achieve the goals they set for themselves.

But that won't be easy.  John worries that these technologies will be adopted only when the country is fully ready to change. And this will require elected officials from both parties, business executives and the citizenry to forge a true partnership.

Like John, I appreciate that modern technology such as mobile and video can be powerful, and lament how few doctors offer these 21st century applications. To solve these challenges, we will need to embrace modern technology as aggressively as businesses in retail, travel and finance have. But based on my conversation with John, I worry that this won't happen until people become aware of what is possible, and demand the same convenience in health care as they experience elsewhere in their lives.  

Dr. Devi Shetty: A cardiac surgeon and humanitarian based in India

Devi runs 14 heart hospitals in India and recently opened a facility in the Cayman Islands. He is a brilliant strategist and mission-driven.  For him, health care is not about trying to earn more money. It’s about placing a high value on human life. In his hospitals, where each complex heart surgery currently is performed for only $1,800, the difference between a child living and dying often is the ability of the family to borrow the dollars needed to cover the costs. So as the operating team cuts the cost of each surgery, it can increase the number of lives saved.

Devi refuses to embrace approaches such as rationing or inferior quality as solutions to the economic challenges that exist, as he made plain in “Putting A Price On Human Life,” a talk he gave at the Stanford
Graduate School of Business. And the world-class results he achieves, superior to most hospitals in the United States, speak to his dedication.  

His outcomes demonstrate the improvements possible in the United States. Hospitals in this country should take a hard look at their processes and eliminate inefficiencies. As Devi has done, we should consolidate specific complex procedures in fewer locations to drive improvements in clinical outcomes. When surgeons do the same complex procedures again and again, and when hospital nurses care for the same type of patient every day, the highest quality outcomes are achieved. And as Devi has proven, high volumes also reduce complications and decrease costs. We have too many hospitals in the United States, with too little volume. Consolidation will be essential.  

But this physician – who treated Mother Teresa after she suffered a heart attack and later wrote an essay entitled, fittingly enough for a cardiac surgeon, “How Mother Teresa Touched My Heart” -- taught me a lesson even more important in the three days I spent with him. I learned that the most powerful force for change in American health care will be humanitarianism.  We will have to appeal not only to peoples’ intellects but also to their hearts.

And so I’m taking this moment to thank all of these thinkers and leaders.  As they’ve influenced and inspired me, I hope I’ve managed in this column to likewise influence and inspire my readers.  Best wishes, all, for a healthy, fulfilling and peaceful New Year.
 
Next month, I will recount equally powerful stories from physicians and patients who have provided important insights into the world of health care and taught me much about the joys and difficulties of modern medicine.

Photo by Alex Proimos / CC BY-NC 2.0