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Popular author Malcolm Gladwell has become something of a fixture on the healthcare speaking circuit and it's easy to understand why. Taken collectively, his books go further than most in explaining the factors that influence and facilitate societal change.

In his groundbreaking book, The Tipping Point, Gladwell challenged -- and eventually changed -- the way we understand the world. He contends that one imaginative person applying a well-placed lever can move the world.

His second book, Blink, examined the power of intuition and its influence on our thinking. One concept that particularly struck me was the idea of "thin slicing" -- filtering the few factors that matter from an overwhelming number of variables. In the context of medical malpractice, Gladwell advises readers to "thin slice" new physicians, trusting their intuition if they sense a physician is not listening to them.

Gladwell has done it again! His newest book, Outliers, is destined to transform the way we understand success.

In Outliers, Gladwell explains the extraordinary success of the Beatles and Bill Gates in the context of generation, family, culture, and class. The lives of these Outliers -- people whose achievements fall outside normal experience -- actually follow a peculiar and unexpected logic, suggesting that context and background matter a great deal.

How does this apply to healthcare? The answer is in a chapter entitled, "The Ethnic Theory of Plane Crashes."

In the late 1990s, Korean Air was internationally admonished following a series of dramatic cockpit failures and subsequent crashes. Multiple investigations led to the same conclusion: poor cockpit communication, rooted in deep cultural barriers, led to circumstances that became deadly.

The chapter discusses three important messages regarding communication: mitigation, crew resource management (CRM), and a concept known as the power distance index (PDI).

Mitigation is a term used by linguists to describe an attempt to downplay or sugarcoat the meaning of what is being said. According to Gladwell, "We mitigate when we're being polite, when we are ashamed or embarrassed, and when we are being deferential to authority."

Although mitigation may be appropriate or even desirable in some situations, it can be disastrous in a cockpit on a stormy night, or an operating room or trauma bay. For the past 15 years, combating mitigation has been a major crusade in commercial aviation.

Gladwell contends that the unprecedented decline in airline accidents in recent years is attributable, in part, to this war on mitigation.

CRM training is designed to teach junior crew members how to communicate clearly and assertively in order to reduce dangerous mitigation. Airlines teach copilots how to challenge the pilot if he or she thinks something is going awry.

For example, the copilot might begin with "Captain, I'm concerned about...," then proceed to "Captain, I'm uncomfortable with...," and if the Captain still doesn't respond, "Captain, I believe this situation is unsafe."

Today, CRM is also playing a major role in efforts to improve healthcare quality and safety.

One staunch proponent is John Nance, a decorated Vietnam pilot, attorney, and author of Why Hospitals Should Fly, a clever book depicting a fictional hospital wherein the tenets of CRM have been completely internalized by the administrative leadership, medical staff, and all front-line caretakers.

The third key communication concept outlined in Outliers, PDI, is one aspect of a model developed by Dutch psychologist, Geert Hofstede. It is rooted in cross-cultural psychology and concerns attitudes toward hierarchy, especially those relating to how much a particular culture values and respects authority.

In cultures with low PDI, power holders try to underplay their power. In cultures with high PDI, the leader's authority is unassailable.

Gladwell relates the impact of Hofstede's findings on aviation industry research. Their battle over mitigated speech and teamwork was actually an attempt to reduce power distance in the cockpit! He notes that Hofstede's work "suggested something that had not occurred to anyone in the aviation world; that the task of convincing first officers to assert themselves was going to depend ... on their culture's power distance rating."

So, what does PDI have to do with healthcare? I think that lowering the PDI -- by means as simple as introducing one another and referring to one another by first names -- can be helpful in improving communication on patient rounds, the intensive care unit, and elsewhere in the hospital setting.

Surely, this may be provocative and threatening to the status quo. It might not work everywhere, but solid ethnographic research has concluded that when things go awry in a cockpit it is much easier to address a captain by his first name than by his title.

I am not suggesting that we must suddenly become buddies on rounds, but knowing who is who and taking a moment to recognize everyone's role on the team would go a long way to improving communication -- and, perhaps, clinical outcomes.

Gladwell's books, and their provocative messages regarding how we think, challenge many of the tightly held, seemingly scientific aspects of our clinical decision-making at the bedside.

But irrespective of varying reactions to Outliers, I believe it would enhance our individual and collective ability to improve communication if we knew a little bit more about CRM and PDI.

Maybe Outliers and Why Hospitals Should Fly should be required reading for every medical student and house officer as a part of the training experience.

Could the way we address one another have an impact on clinical outcomes? If this is the case -- and I believe it is -- we should learn how to communicate appropriately in a simulated training environment so that it becomes routine in the hurly burly of everyday work.

Gladwell asks why it is so difficult to acknowledge the fact that each of us comes from a culture with its own distinctive mix of strengths and weaknesses, tendencies, and predispositions. "Who we are cannot be separated from where we are from -- and when we ignore that fact, planes crash."

And patients die.

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