Thinking Citizen Blog — Fixing American Health Care (Part II): Atul Gawande, David Goldhill, Emma, and me

Thinking Citizen Blog — Thursday is Health, Health Care and Global Health Policy Day

Today’s Topic — Fixing American Health Care (Part Two): Atul Gawande, David Goldhill, Emma, and me

Metaphors are bridges to understanding. What is the best metaphor for the US health care system? Atul Gawande, the surgeon, Harvard Medical School professor, best-selling author, and perhaps most respected analyst of the US health care system came up with this image: “Porsche brakes, a Ferrari engine, a Volvo body, a BMW chassis.” In other words, a really, really expensive “pile of junk” that won’t get you where you need to go. The next image to fix in your mind is that of the $635,000 bill that David Goldhill’s mother received after, in the words of her son, “The American health care killed my father.” Goldhill had been the CEO of a tech company before this personal disaster. He took a leave of absence to figure out how this catastrophe could have happened. When he figured it out, he wrote an article for the Atlantic entitled, appropriately, “How American Health Care Killed My Father” (2009). This article was singled out by my daughter Emma when she graduated from Harvard with a degree in neurobiology with a minor in global health policy, as the single best article she had ever read on health care policy (or anything else for that matter). I took her advice. She was right. Have you read it? Well, if you haven’t you should. But it is very, very tough going. I had to read it at least five times. There is also a Youtube speech by Goldhill which you should also watch. Probably, a similar number of times unless your IQ is double mine. But, perhaps, Goldhill’s most important point is that the biggest myth about health care is its complexity. You can summarize the problem in one word: incentives. That is also true. Do you get it? Is everything clear now? To close the circle on Gawande, Goldhill, and Emma: Goldhill was a guest speaker in the best course she took at Harvard — which was co-taught by none other than Atul Gawande. Experts — please chime in. Correct, elaborate, elucidate. Specifically, if you think there is an article or video better than Goldhill’s, please, please, please, share.

INCENTIVES, INCENTIVES, INCENTIVES — whatever did Goldhill mean?

1. Have you ever heard the expression: “follow the money.” Same idea.

2. For engineers understanding how buildings stand up is all about “following the load path.” Same idea.

3. Ask an economist to summarize all of economics in a single word, there are only two answers you will get: “scarcity” or “incentives.”

NB: Incentives is the better answer of the two.

CLICK, CLICK, CLICK — a master key opens many locks

1. Why didn’t anyone pay attention when, in 1982, I wrote a manual for teachers in Harvard’s general education program explaining how to fix a complex broken system?

2. Why did a similar plan for restructuring the dysfunctional research department of a major investment firm result in a lower rather than higher year-end bonus?

3. Why did the Catholic Church not crackdown on the rampant pedophilia?

NB: “Incentives.”


1. Translation #1 — incentives means, first of all, keeping your job. Not doing the best you can. That could be a recipe for ostracism, loss of bonus, loss of job, unemployment, divorce, alcoholism, suicide. What lawyers call “the parade of horribles.”

2. Translation #2 — incentives = survival instinct.

3. Translation #3 — incentives = inertia = if it ain’t broke don’t fix it. I’m doing ok. I’m doing fine. Don’t mess with it. Keep the nose to the grindstone. See no evil. Hear no evil. Speak no evil.

NB: Just remember what I call the Vatican rag: Whatever you do, don’t think. If you have to think, whatever you do, don’t speak. If you have to speak, whatever you do, don’t write it down. If you write it down, whatever do, don’t publish. If you publish, don’t be surprised.

The Goldhill Video

Atul Gawande’s metaphor

Victor Fuchs is the third health care analyst I count up there with Gawande and Goldhill. An emeritus professor at Stanford, he taught there for decades. He is the third of the three photographs above. The first is Goldhill, the second Gawande.

Biographical background on Fuchs, Gawande, Goldhill

Tom Lehrer’s Vatican Rag:

To be continued.


Please share the most interesting thing you learned in the last week related to health, health care or health care policy — the ethics, economics, politics, history…. Or the coolest, most important thing you learned in your life related to health are or health care policy that the rest of us may have missed. Or just some random health-related fact that blew you away.

This is your chance to make some one’s day. Or to cement in your mind something really important you might otherwise forget. Or to think more deeply than you otherwise would about something that matters.