Politics Is The Opposite Of Entrepreneurship

There seems to be one main similarity between politics and entrepreneurship; they both try to create change.  However, the methodologies that they use to make change happen couldn’t be more different.

Politics may seem like the older brother of entrepreneurship, but when you inspect politics close up it seems more like that unsightly Uncle, who smells a bit odd and may have spent time in prison.

The Entrepreneurial Journey

This is a summary of pretty much every entrepreneurial autobiography I have read.  I should stop buying these books, but there’s usually a few nuggets of valuable information in each book which are quite insightful.

The classic story of the entrepreneur goes like the following.  A young (usually male) person gets exposed to a gap in the market place or a pain point in their own life.  Fuelled by ambition, a longing to create a real impact and the hope of breaking away from a life of monotony the young entrepreneur experiences what is commonly called an “Entrepreneurial Seizure”.   This is the moment where he says “Screw it!  I’m going for it!”.  At this point no matter what his family and friends say, it only adds to the fire of ambition to go for it*.

Our young protagonist then gets started on creating their product or service.  Due to a lack of funds he sells his belongings, downgrades his car, takes on more shifts at work, rents out spare rooms in his house and starts wrangling banks and family members for some money.

The entrepreneur then realises that no matter how much money they gather, they won’t be able to create the business they saw in their vision by simply gathering money.  He needs to actually create a business which generates money and allows him to re-invest in the company and grow the business with money from actual customers.

With this knowledge in mind, the entrepreneur creates a streamlined business serving a small group of customers with a very niche product.

After months and possibly up to a year of hustling for new customers, autodidactism and networking the young entrepreneur finally hits product-market fit and has several million dollars worth of business a year.

Now it’s just a case of scaling the product or service to serve as many people as possible.

Before the entrepreneur knows it they are entertaining offers to sell his company at sums needed for an early retirement.

The Political Journey

Contrast the above journey with those involved in politics.

Someone in a given organisation or society wants to make a difference by changing policy.  Usually the ideas which inform these changes are borne out of class rooms, books, meetings and gossip rather than the kind of acute pain which causes someone to start a business.

Let’s take the example of an employee who is in a large organisation that wants to work his way to the top and make change happen.  She will necessarily go through a number of jobs and work up a hierarchy.  On this journey she will discuss her thoughts with people at the coal face and have a clear idea of the type of change she wants to make.

However, as she gets nearer to the top she will realise that the system is not as simple as she thought.  All of a sudden she will have to work hard to please shareholders, board members, unions, lobbies, fringe groups and also the people who are actually doing the coal face work which she wanted to help in the first place.

Usually this person will end up doing work which is ethically questionable on the way to the top.  “I know it’s not the right thing to do.  But, if I do this I’ll be able to get to the top and make the positive difference people need.  It’s for the greater good.”.

This type of cognitive dissonance seems to be quite prevalent among politicians.

When this person finally does get to the top, the policies and change she wanted to create will also get tainted by all the different vested interests mentioned above.  The fragment of a good idea that our politician had will be deformed from the start and likely not result in much of a change at all.

Contrast

My main point with this post wasn’t to display why politics is inefficient, but it’s to show how entrepreneurship and politics are fundamentally the opposite of one another.

Entrepreneurship is bottom-up.

Politics is top-down.

This also explains why politics rarely produces change that people want and why entrepreneurship must always result in change people want.

In entrepreneurship, when you build a product or a service, you have to generate money to allow it to keep growing and spreading.  To generate cash, you must have produced something that the market has to pay for.

All entrepreneurs know that their initial idea for a business will be way off course.  In fact because of this there has been a whole movement in the last decade called “The Lean Startup” which advocates getting something out into the market place, learning and iterating your business plan.  The assumption in entrepreneurship is that the founder actually knows very little with regards to what people want.  So you may as well get something out there and see if there is any traction.

This way entrepreneurship must produce products and services that serve people’s wants and needs from the get-go.

In politics, ideas are usually made in something like a boardroom.  Ideas do not get validated by something like “The Market”.

I find it quite interesting how even if politicians want to make change, they can never do it in the way they wanted.  This is obvious if you understand that there are too many vested interests pulling you in different directions, that the world is far too complex to understand let alone predict and that the world is in continual change.

*As I’ve mentioned before, starting a business, as long as it sticks to Thalesian principles is actually the wisest decision someone could make.

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Thalesian Principles And Why More People Should Start Startups

The purpose of this blog post is to illustrate how startups are different from traditional businesses, but also why more people should start a startup.

What’s A Startup??!

There is a misconception that any business “is a startup”.  In fact most businesses are not startups.

Is that corner store a startup?

Is a website that you have created which is bringing in a small amount of revenue a startup?

Is a digital agency (web development company) a startup?

If you register as a freelance doctor/artist/consultant/web developer are you a startup?

The answer is no, but could be a yes.

Allow me to explain.  Startups are a special type of business as they are designed to 1. scale and 2. scale fast.

If you look at the above examples it is incredibly unlikely that any of these will be able to scale to serve a massive number of people or do it quickly.  There are exceptions such as Starbucks which found a way to scale and do it quickly.  However, businesses which require a lot of human resources are the hardest type of business to scale and likely will never be able to do so.

Equally a digital agency will find it hard to scale.  The bigger they get, the more people they will need to hire, the more they will have to charge to cover their overheads and therefore they will price themselves out of the market.  Again, anything which requires human intensive work is very difficult to scale.

How about websites which bring in a little bit of money?  Most are not startups as they won’t be able to scale and grow to serve large numbers or people.

In essence a “startup” is synonymous with growth.  They are the one and the same.

Thalesian Principles (A Story About Startups)

Startups are old news.

Thales was a pre-socratic Greek philosopher.  He also became very rich.

Thales invested in olive presses.  When there was a good harvest and therefore high demand, he would rent out the presses at a high rate.  One version of this story says that Thales predicted a good harvest one year and so bought all the olive presses due to his analytical skills and prediction that olive presses would be of great need.

Indeed Aristotle himself said that this shrewd business decision was due to Thales’ philosophy skills.  However, others have noted that it wasn’t Thales’ extreme intellect that helped him to make the decision to invest in something which may not have returned any money, but because Thales understood that some investments have a convex (unpredictably high) return on investment.

Thales understood that it didn’t matter what he invested his money in as long as there was a convex return on investment.  All he needed to make sure was that there was a limited downside (the initial investment) and a convex (near unlimited) upside.  He understood that even if he lost the money he invested in olive presses, it wouldn’t affect him too negatively and that he would simply be able to invest in something else down the line.

Why More People Should Start Startups

They have finite limited downsides and possibly unlimited upsides.

It may seem to outside observers that entrepreneurs seem to risk it all by going on their ventures.  But most entrepreneurs are actually very safe and know how much downside they can handle on a given venture.  As long as there is a limited downside and an unlimited upside, entrepreneurs are happy.

If you can design a business* which will grow and grow quickly (as in a few years), this means that you may end up with an incredible return on your initial investment.

This is why I think more people should be starting well designed startups instead of putting their money in traditional investments such as 401Ks and pensions etc.

Let’s say that you can put aside several thousand dollars a year to invest and do what you want with.   If you put your money into a 401k or something like property then after a certain number of years you will get a certain predictable amount of money back.  The problem with these more traditional investments is that it takes many many years to get anything back.  Also, you are handing over your fate to society, the government and the economy.  If the markets crash, if there is a recession or if Wall street screws up then either you’ll break even or you’ll end up losing your money as so many people did in 2008.

So, the options you have are to either put your money into something which will give “predictable” returns (which will be either low or non-existent) or put your money into something which can actually generate lots of wealth – like a startup!!

*There are ways to design your business in a way which allows it to become scalable, but this topic is too large for this blog post.

Everyone Should Be On Statins!

This is the mantra of the medical profession.

When I am seeing patients basically every man over the age of 60 and every woman over the age of 75 is advised to be started on a statin.  The algorithms on my computer (anyone with a QRISK2 score over 10% is advised to start on a statin as per the national guidelines) tell me to give it to them.

It seems that every few weeks there is a news article singing the benefits of taking statins.

Just to step back for a moment.  Statins are a group of medications which lower cholesterol.  Lowering cholesterol, it seems is associated with lowering the risk of death from a heart attack or a stroke.  Statins have always been controversial as such a large number of people are advised to take these medications.

I think statins are a perfect example of a drug class which has a lot of evidence espousing its benefits but little evidence showing that it may be harmful.  As I wrote in my previous blog post, the absence of evidence is not the same as evidence of absence.

The fact is that studies will show that statins “cut the risk of having a heart attack by X%”, but the hidden side effects and long term health disadvantages are not measured and in a lot of cases cannot be measured.

For example are statins associated with breast cancer?  Are they associated with bowel cancer?  Does it increase the likelihood of other diseases such as diabetes?  How about if you’re already a diabetic, does it make your diabetic retinopathy worse than if you weren’t on a statin and cause earlier blindness?

None of these questions have answers and they never will have an answer until it becomes painfully obvious as drug companies and the scientific community will always go looking for evidence which should result in treatment.

What do I do with my patients?  I explain that guidelines advise that they should be on a statin as it may decrease their chances of a heart attack or a stroke.  But I also tell them of the possible listed side effects and also explain that “all medications have side effects and risks which vary from person to person” and that if he/ she doesn’t want to continue it then they are free to stop at any point”.

Why Your Family Doctor Tells You To Go Away And Take Paracetamol/Tylenol

This post may get a little heavy on theory and scientific jargon.  Possibly one of the reasons why there are often so many disagreements between patients and physicians.

Introduction

I was having dinner yesterday evening with some friends.  At the table there were a group of doctors, a computer scientist, a technical consultant and a health economist.

Discussion quickly turned to inconsistencies in healthcare between different countries and also amongst different physicians.  I am going to present my thoughts on giving any form of treatment to patients in this post and why it’s a good thing if your doctor tells you to go away and take paracetamol (aka Tylenol for all you Americans out there).

If current guidelines would permit and if medical committees would allow, I would be happy to give even less treatments to my patients than I do today.

Positive (Naive) Treatments

We have all heard anecdotes such as the following;

“I saw Dr X and she didn’t know anything!  She just told me to take Paracetamol!”

“Dr Y didn’t recommend a x-ray!  I know that Dr Z would have if I saw her!”

We are living in an interesting time.  We have an abundance of information*.  Medical technology and the choice of medications has increased into their hundreds in the last few decades.  There has also been an explosion in the number of procedures to choose from.

I want people – both clinicians and patients – to stop and consider whether this is a good thing.  Is it good that more and more people are on more and more medications?  Is it a good thing that so many people are having CT scans (and thus being exposed to so much radiation), invasive investigations and procedures?

Most of the public and indeed it seems, most of my patients seem to think so.  I say this in view of how often they are pushing me to give them antibiotics or send them for brain scans.

My argument is that although “positive evidence” exists for giving treatments, the antonym (“negative evidence”) doesn’t or is much harder to come by.  To compound the issue medical councils and regulators do not even recognise/are cognisant of such things.

What I mean by this is that most scientific/medical evidence study what effects an intervention has on patients with regards to a very specific outcome.  For example if a given drug is thought to lower the chances of getting bowel cancer, then the study will look at if the incidence in the cohort of people taking that drug is lower in comparison to a control group.  However it completely disregards unforeseen effects of the medication.  For example does the drug cause certain other types of cancer?  Does it cause bone degeneration?  Does it cause more heart disease?  The evidence doesn’t exist and pharmaceutical companies and physicians are unlikely to go looking for such findings as the scientific community in general, are so biased towards finding positive results and therefore more interventionism.

It is true that more evidence causes doctors to prescribe more and carry out more interventions than is needed.  The absence of evidence is not the same as evidence of absence.

Let us take the example of tonsillectomies.

In the 1930s tonsillectomies were very common.  The thresholds for operating on children were much lower than it is today.  There was a study carried out on just shy of 400 children in New York during this period.  In the study they took the children to a doctor and asked whether these children needed to have a tonsillectomy.  174 of them were recommended to have the operation.  The remaining children were then taken to another doctor and 99 of them were advised to have a tonsillectomy.  They took the remaining children to another doctor and another 52 were recommended to have an operation.

Consider that there is a 2-4% morbidity rate today (not back in the 1930s when rates were much much higher) and that 1 out of 15,000 children will die from the procedure or as a complication of the operation.

Obviously more children are alive today, simply by carrying out less treatments.  If the morbidity and mortality statistics were available in the 1930’s it is likely that less operations would have been performed.  More-so, I think the number of parents giving consent for such procedures would have fallen also.

I think it is easy to see why tonsillectomies are much less common nowadays.  No one would argue that we should go back to doing more of these operations today.  Can a similar thing be said about other treatments patients are given today?

Iatrogenics

Iatrogenics are the illnesses caused by physicians.  For example, if a patient is subject to certain procedures, such as radiotherapy or they have an adverse reaction to a medication they are said to have suffered from an Iatrogen**.

Although doctors are somewhat aware of iatrogens, medicine is still very naive when it comes to possible risks of different treatments – due to absence of evidence.

It would be foolish to think that doctors know what harmful effects there will be in the future for patients if they are given treatment today.

Medicine is littered with examples of absence of evidence (not evidence of absence!).  A famous example is that of Thalidomide.  Thalidomide was used during pregnancy as an anti-emetic.  It seemed like an obvious treatment to an obvious problem back when it was widely used.  Thalidomide helps pregnant women overcome nausea and eases their pain, therefore it is a good thing that they receive treatment it was thought.  Only after years did it become apparent that Thalidomide was teratogenic and as a result caused deformities in the foetus.

You see, lack of evidence (of harm), is not the same as absence of evidence (of harm).

Thalidomide is an interesting case study as the malformations caused by the drug were so obvious yet it took so many years for scientists to link thalidomide to the harm it caused.  It is very hard to extrapolate and find causality in such a complex world.

Think of all the treatments, medications and procedures we carry out today.  I wonder what side effects people are suffering from.  It is impossible to say right now, but I can guarantee that there are plenty out there.

The Medical System

This is the crux of the problem.  There may be short-term benefits with certain treatments.  However, with a lot of medications and treatments there is often very little or no evidence that such therapies are actually helping patients (for example, some studies have shown that water is just effective for treating depression as antidepressants are).  Not only this, but there is absence of evidence of the risks of treatments.

The reason people continue to get treatments from their physicians is because of presence of some information which could mean that some benefit may be gained by the patient.

This leaves doctors in a very difficult position.  We are continually forced by medical guidelines to carry out more and more investigations and treatments.  On the other hand, patients are also becoming more and more pushy demanding treatments they have heard of from the media or their friends or family.  The problem is that if no treatment is given and something goes wrong then the doctor is held liable for the “mistake” of not treating.  Doing something – any kind of treatment – seems to be recognised, but doing nothing is currently indefensible.

The case of Michael Jackson immediately springs to mind.  Conrad Murray was sentenced to four years of prison due to Involuntary Manslaughter.  However, would not treating Michael Jackson have been defensible in court?  This is the very real scenario that all practicing doctors face.

No one seems to have an understanding of the real risks of modern day medicine.

What I am suggesting in this blog post is that doctors, patients and medical guidelines are all blind to the harms of the medicine we practice today.  The side effects of the overuse of antibiotics, antidepressants unnecessary operations etc will not become fully apparent until many more years have passed.

Now, having realised that medical treatments today may be much more likely to harm you than you initially thought, would you still like that course of broad-spectrum antibiotics?  How about a nice MRI scan of your back so you can be considered for a spinal fusion and laminectomy?

Any takers?

Thalidomide…

Ps. A good question to ask your doctor is: “What would you do if you were in my position?”, instead of “What do you recommend I do?”.  You will be shocked to see the difference in recommendations as your doctor is much more aware of Iatrogenics (although they are probably greatly under estimating them).

*Interestingly this abundance of so much information will add to more and more un-informed treatments and long term morbidity.  As mentioned there isn’t enough data at all on negative information – only on positive intervention and medication.  “Big data” is all the rage in the tech scene right now, but actually this is a disaster in the making as more people will be diagnosed with dubious pathologies and have excessive treatments for such conditions.

** As an aside – it is interesting to note that medicine is pretty much the only field in the world where there is a study of iatrogenics and where iatrogenics are talked about.  If you speak with economists, politicians etc then you will not find a single person who is aware of what an iatrogen is or how to assess for them.  It’s just not in the common discourse.