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AHIP: Gawande, Gladwell on Healthcare's Chauffeur Problem

Margaret Dick Tocknell, for HealthLeaders Media, June 25, 2012

Gladwell presented the chauffeur analogy as an example of what happens when new technology is introduced. At first everyone is unfamiliar with the technology and needs a guide. When automobiles were first introduced they were embraced by the wealthy, but because they didn't know how to drive they hired chauffeurs.

Families needed the chauffeur to bridge the technology. Chauffeurs had power; families couldn't travel in the car without them. But, over time as more people became familiar with cars and learned to drive, chauffeurs lost their power.


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Gladwell pointed to phototcopying as an industry that let go of its chauffeur and grew by leaps and bounds. He explained that when Xerox first introduced its machines in the 1960s a Xerox rep would be on site to take care of the machine. Offices paid a royalty for the number of copies used. "Xerox was the chauffeur." As other companies entered the business and competition increased, the industry changed. The chauffeur became less important.

He noted that two processes that have happened quickly in other industries, commodification and customer control or consumerization, have been slow in coming to healthcare. The reason, said Gladwell, is the healthcare industry has been unable to compromise on the quality continuum.

"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse.

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3 comments on "AHIP: Gawande, Gladwell on Healthcare's Chauffeur Problem"


davetrindle (6/27/2012 at 1:22 PM)
Doctors will always have a role, just as chauffers will. Nevertheless, because there has been a chronic shortage (intentional or otherwise, doesn't matter), doctors will soon be overtaken by the practitioners who are moving at an exponential pace into the vacuum doctors created. There are PAs (physician assistants) who are more appropriately trained for preventive, routine, and family care that has been to a large extent abandoned by the MDs. The numbers of PAs are growing so fast, MDs will lose their monopoly in the very near future (BTW I don't blame the MDs, it is the way the system has moved, most MDs are doing the best they can and deserve our respect.) Meantime, the majority of healthcare will soon be in the hands of PAs,nurse-practitioners, and the rapidly growing urgent care industry. And this is a good thing for health (and health care costs) in our country. p.s. in answer to the person using the you can't "repair your own car" analogy, obviously have never changed their own oil, never been to wide range of alternative services other than the dealer or full service repair shop. There are jiffy-lubes, brake specialists, tire specialists, exhaust specialists, transmission specialists, none of whom could claim to be full service repair shops, yet they get the job done more quickly, more conveniently, and at lower cost.

johnlynch2 (6/27/2012 at 8:54 AM)
Both speakers make valid points and both are off base. Gladwell is right in that patients can, and must, assume more responsibility for their own care, but there are degrees of intermediaries. It's not just a chauffer or no chauffer; there are also cabs, car rentals, and even public transportation. Self-managed care can and does work, but it needs professional supervision and direction. Nurses and other physician-extenders can do this low-tech, high-touch support better than doctors - and more cheaply. Speaking of which, Dr. Gawande is correct that coordination and integration of medical services is certainly a missing link in our health care. But fixing this via ACOs may not be the big cost-saver that many predict. The most established ACO in Massachusetts, for example, is also is most expensive ambulatory provider network - and by a large margin. The real missing link in our broken health care system is informed consumers. This is crucial to all efficient markets. If patients were more skeptical of every test and procedure their doctors recommend - many for financial benefit alone - there'd be fewer bogus spinal fusions, cardiac stents, and arthroscopic surgeries of arthritic knees. The key to escaping poverty is education and the key to avoiding medical impoverishment is education as well.

Senthil Nachimuthu (6/25/2012 at 6:09 PM)
Asking patients to administer their own treatments is similar to asking people to fix their own cars, not asking people to be chauffeured. I think Malcolm Gladwell is comparing apples and oranges, when he compares the healthcare professional to a chauffeur, when he should compare the healthcare professional to a car mechanic. People can tinker with their own cars if they are ready to accept the consequences. Unfortunately, cars are replaceable whereas people are not, in addition to the fact that human bodies and healthcare are a lot more complex than automobiles.