The Business Of Medicine

There’s something unique about the business of medicine.

In a traditional business such as a burger joint, if you have more customers and sell more burgers, then the restaurant owner will make more money.

But in medicine, the more patients a clinic sees and the more patients a hospital serves, the less money they often make.

For example in my own clinic; The more patients I see, the more administrative work there is for my admin team (which I have to pay for), the more nursing tasks that will need to be carried out by my nursing team (which I will need to pay for) and the more paper work I will need to do (meaning more hours worked by me, meaning my hourly pay rate decreases). [1]

Why is the medical world so different to other industries?  

This essay is about i) money, ii) entrepreneurship and iii) entrepreneurship in medicine.  If you think about it, all three of these topics are mysterious in their own right.  But when you combine all three, things get a whole lot weirder.

Money

There’s something really captivating about money.  If you’re ever giving a talk and hold up a £20 note, people will immediately stop doing what they’re doing and listen to you.  It’s quite mesmerising.  But why does if have this effect on people?  I think it may be a combination of respect and awe.  Not dissimilar to the way people react to a holy religious text.

There are a lot of theories about where money originated from.  The most famous myth is the one perpetuated by Adam Smith [2] who wrote the capitalist “Bible”; The Wealth of Nations.

Adam Smith argued that before humans had money, we would trade and barter.  For example if you grew potatoes and you needed some clothes, then you would have to trade your potatoes for the clothes.  Of course certain clothing items would cost more potatoes and some less potatoes.

The story goes that this form of bartering was too difficult to implement on a large-scale and that there was no robust way of keeping track of how much things would cost.  Is one potato equal to two apples?  What happens if the clothes dealer didn’t need any potatoes at the time?  Does that mean that people who grew potatoes couldn’t get clothes all of a sudden?  The obvious solution it seems was to create some form of universally accepted currency that people could trade freely for different products and services; Money.

The problem with this story is that there is absolutely no historical evidence that this is how money came into existence. [3]

Societies seemed to have functioned fine before money came into existence.  Most societies worked like this; If you were a butcher and the local clothes dealer came to pick up a chicken, you would just keep a mental note of this.  And then you would recoup the favour at some point in the future.  People would keep a mental note of who owed them what.  Sometimes, people would trade “IOUs” – if the clothes merchant gave you an IOU, you as the butcher could go to your local shoe smith and trade the IOU.  The clothes dealer now owed the shoe smith.  These IOUs were often traded locally and didn’t stray too far away.

But where did money actually come from?

The story of where money came from in England has been replicated all across the world.  It was initially created by the monarchy and the government to feed its army.  When an army was moving through the country, it needed food and water as well as a number of other essential services.  Of course if there was no money then the army would leave a path of destruction behind it and they would ravish the landscape.

So some business savvy people approached the king for a loan[4].  Could the King provide some pieces of paper with the royal families stamp?  The stamp would prove that the notes themselves were valuable and would prove that the notes represented something of real value – a fraction of the gold the king held in his possession.  The army could use these notes to trade for products and services.  The people who got some of these notes would be able to continue to trade them amongst themselves as it had the seal of the king on them, proving their worth.

The King was told that he would get more of these notes back from the peasants that traded them as “tax”.  The King could then use the tax to contract out work  to people who would work for more of these notes and even more tax would be collected.  To this day the initial amount loaned from the king has not been paid back in full.

Of course not, because if it were to be paid back then the British Pound would collapse and cease to exist.

The point of this brief overview is that money has always been a means to create a “market”, where products and services could be traded and where taxes could be paid to the King and government.

But what’s really strange is the fact that money supposedly represents something which is “inherently of value” i.e. gold.

But is gold actually of value?  It’s not particularly good at creating tools from, the only use people have for it seem to be making ornaments and jewellery.

Indeed in societies where gold was abundant, the local people didn’t really care about gold. They were confused when foreigners came to their land and showed a strange obsession with the stuff. [5]

The fact is that objectively, gold has no inherent value.  You can’t find some hidden “value” in it when looking at it under a microscope for example.

The only reason we believe gold is valuable, is because we believe that other people will also believe it is valuable and trade with us.  This is the same with money.  The only reason we believe money is valuable, is because we believe we can trade these pieces of paper with other people who also believe that these pieces of paper are valuable.

But the fact is that money is inherently not of value.  It’s just that there is a collective belief amongst humans that it is of value, which makes it valuable.

If everyone woke up tomorrow and decided that money is actually just pieces of useless paper then the whole financial system would collapse.

But while we all believe money is real, it is real.  We can trade these pieces of paper for real products and services – we can gain real knowledge by paying for an education, we can cure a real chest infection by paying for an antibiotic.

Money is a human construct which allows us to trade something which exists only in the human mind for real objective products and services.

Entrepreneurship

Entrepreneurs are a vital part of the capitalist system we live in today.  They are the reason that society has thrived in the last few hundred years and why the world is wealthier than ever before.

Before entrepreneurship and the advent of money we lived in a zero-sum world  i.e. if someone became rich, it was because they took and hoarded wealth from the poor.  But with money and the capitalist system things really changed.  All of a sudden entrepreneurs could create new wealth by “creating value”.

Fast forward to today and entrepreneurs all over the world are creating innovative products and services to sell to the market place, which allows them to create more jobs and produce more, which creates more taxes and more circulating money.

The world has more wealth today than ever before.  When someone becomes a millionaire in China, he or she hasn’t done it by stealing money from someone in England.

Entrepreneurship is open to more and more people today.  With the cost of creating value forever decreasing.  Now even a Harvard student can launch a multi-billion dollar business from his dorm room.

Much of the “value” created however, is again only in the human mind.  When Zuckerberg created a social network, so that people could connect easier and share photos, where is the objective value?  Can someone look at Facebook under a microscope and find the value?  If an alien came to Earth would it be able to detect the “value”?

An alien would certainly be able to carry out scientific experiments and detect oxygen (an objective reality) and find swathes of H20 (another objective reality), but not the “value” in Facebook.

This objective lens can be applied to most things.  Is the owner of an airline, who transports millions of people around the world for their annual holiday really creating anything objectively valuable?  Actually, the value of hopping on a plane and travelling to another country is only valuable in the mind of the person buying the plane ticket.  There is no “objective value” in this case.

Entrepreneurship In Medicine

It is striking how often I hear in the news that the medical world is going to be “disrupted”, how new businesses are going to come and change how doctors practice medicine forever and how innovative services are going to provide massive “value” for patients.

Despite these claims, which have been floating around for decades now, the medical industry seems to be as rigid as a rock.  Even much of the current technology being used – for example the Electronic Health Records (EHRs) – which theoretically are easy to improve upon and recreate were built in the 1980s.

But why?  Where’s the innovation and new technology which is sweeping all the other sectors?

I believe it’s because medicine is where subjective reality (“money”, “value”, “creating value”) meets objective reality (cancer, infections, disease etc).

Doctors and the medical industry have an aversion to bullshit.  Doctors have long decided that they will not use sugar pills and trick patients into thinking that they are receiving real treatments, they refuse to serially dilute molecules in the hopes that a cancer will be cured (as in homeopathy, which is not based on evidence i.e. an objective reality).

Granted, it could be argued that doctors have taken this too far.  There is real evidence that placebos do help patients and reduce pain and suffering, but the medical community refuse to play this game. [6]

In my own clinical practice, I know something as simple as laying a hand on a patient and examining them thoroughly (even when not needed), puts the patients mind at ease and often reduces the pain they are experiencing.  But a lot of doctors would not admit that they do this.

I suppose that if doctors did start to use placebos on their patients and the treatment “worked”, then where would we draw the line?  By giving legitimacy to subjective forms of treatment, would doctors be validating them all?  Suddenly, doctors would start to resemble homeopaths and fortune tellers.

But this is precisely the reason why the capitalist system does not sit well with clinical medicine.

If someone develops an app, which diagnoses more people with atrial fibrillation even though they are asymptomatic and have no comorbidities, it will lead to more diagnoses of this condition.  But the objective evidence shows that these new diagnoses would not reduce the number of complications as a result of the condition.  This is the reason why atrial fibrillation is not screened for[7].  Even if patients / customers want to be diagnosed this is not a good enough objective reason to go ahead and screen the general population.

Equally if someone develops an app which increases access, for example to primary care physicians, if the correct cohort of patients do not use the new service (example if it is only used by healthy, young patients), then what is the “objective value” that has come out of it?  It could be argued that the old and unwell are being deprived of medical help at the expense of those who don’t need it.  Again, “subjective value”, where the fit and well feel like they have the right to get medical help is not the same as “objective” truth.

Medicine will be relatively slow to change because of this.  Change requires an objective truth in medicine, not just the creation of “subjective value”.

 

Notes & References

[1] – Michael Porter et al. have been writing about this problem since the 1980s.  They propose that a “value based” system should be instituted in the healthcare industry, where money earned by clinics and hospitals would be correlated to how much “value” they provide for their patients, rather than what happens now; a fixed “pie” of money which is provided to carry out a poorly defined set of work.

But the problem arises when you realise that not all medicine is objectively valuable, but only subjectively to the patient.

This is a point that is not addressed in their works, which may go some way to explain why “value based care” has not been implemented in over thirty years, since their works were initially publicised.

[2] – Adam Smith didn’t know any better at the time, because he had limited access to historical records.

[3] – The definitive anthropological work on barter was carried out by Caroline Humphrey, from Cambridge University.  As she put it in her work; “No example of a barter economy, pure and simple, has ever been described, let alone the emergence from it of money; all available ethnography suggests that there never has been such a thing”

[4] –  In 1694 a consortium of bankers made a loan of £1,200,000 to the king.  They charged the king 8% interest and they also charged interest to the clients who borrowed the money from them(!)

[5] – In 1519 Hernan Cortez and his conquistadors invaded Mexico.  The Aztecs who lived there used gold to make statues and jewellery, but they didn’t view it as valuable.  In fact they used cocoa beans to trade.

When the Aztecs asked why Cortez had this fascination with gold, Cortez replied: “Because I and my companions suffer from a disease of the heart which can be cured only with gold”.

[6] – The debate about using placebos continues to this day amongst clinicians: https://www.bmj.com/content/363/bmj.k3889

[7] – The BJGP from Jul 2017 gave a good overview about the issues surrounding screening for AF: https://bjgp.org/content/bjgp/67/660/296.full.pdf.

The National Screening Committee have also published their thoughts on their website: https://phescreening.blog.gov.uk/2019/01/11/dont-let-good-intentions-undermine-population-screening-principles/

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What It’s Like To Start A Business

I received a letter from a fellow healthcare worker the other day.

She wrote to me regarding a patient of mine, demanding that I “do something”.  Her letter was, to be quite honest, rude and uncalled for.  She knew very well that I had already seen the patient, assessed the patient correctly and that the patient had the ability to make decisions regarding her own medical care.

This isn’t an uncommon occurrence.  I spend a significant part of my working day telling patients and other healthcare professionals that nothing needs to be done.  And that often doing nothing is more beneficial than doing something for the sake of doing it.

But why are patients and people in general like this?  Why, for example, does a patient with lower back pain for a grand total of two days turn up at my clinic demanding an urgent MRI scan, which would bring no benefit to the patient whatsoever?  Why do they get angry and upset when I explain that physiotherapy and lifestyle changes are the way forward?

I think there’s a simple answer:

The patient is worried that they are going to die*.

And who can blame them for having this outlook?  Most people from a young age have been conditioned to think that death is lurking right around the corner.

The thinking even in primary school was something along the lines of: “If you don’t do well in school, then you’ll end up without a job, then you’ll end up homeless and then you’ll die a sad and lonely death.”.

Of course for the people who made it through school and are not dead – which happens to be the majority of mankind – the above line of reasoning is clearly false.

Yet the same thinking often persists and manifests itself in absurd ways later on in other parts of  their life.

riskysport

This is not what it’s like to start a business

I think a lot of people avoid going into business for themselves due to this reason.  Even though it would be better for themselves, their family and those they serve to go it alone, they don’t.  Or worse, they say “someday”…

The fear of death manifests, in the form of being someone elses devoted employee for the whole of their healthy adult life.  “I’m not a risk taker”, they tell themselves.

Look, I get it.  It’s fine if you are truly happy as an employee.  What I can’t tolerate is when people make up BS excuses for not doing something with no logical reason.

So how to think about things?  How do you decide what is truly risky and what isn’t?

The Two Types of Risk

I believe that there are two types of risk.

  • Compound Risk

This is the type of risk which builds up over time and then ultimately does result in poor life outcomes such as bankruptcy and death.  Ironically people take these risks all the time without any consideration for their ultimate effect.

For example the decision to not exercise today, or the decision to just have that pizza instead of sticking to the diet.  These types of risk compound over time and then one day give you a heart attack or stroke.

  • Simple Risk

These are risks that can be calculated and taken with no hidden / compound effects.  If for example you decide to buy a car with cash you can easily calculate if you can afford it and what type of risk a reduction in your bank balance will lead to.

The problem is that these two types of risk often become conflated. 

People think that starting a business is a “compound risk” instead of a “simple risk”.  When in fact starting a business has a limited downside and a possible large upside.  It’s a calculated, simple risk.  

Or people think that “eating one more slice of pizza “is a “simple risk” and not a “compound risk”.  They think that one more slice of pizza or drinking one more alcoholic drink is no big deal.  They fail to realise how the risk compounds with time and that that “one more” may lead to an unpredictable heart attack somewhere in the future.

This conflation of the types of risk is what’s happening in the patients who have back pain demanding that “something has to be done”.  They don’t realise that when a doctor has competently assessed you and has ruled out “red flags”, which could indicate a serious underlying issue, that the risk will not compound.  It doesn’t matter if you’ve had the back pain for a day or a year.  If the clinical scenario has not changed then the risk is still a “simple risk” and will not “compound”.

Yes, physiotherapy and lifestyle change is still the way forward.

*Usually men and women alike tend to think that they have metastatic cancer if they have lower back pain.  They fail to realise that they have developed the pain because their body is trying to signal to them that they have poor muscle development (usually due to being overweight and inactive).

It All Starts With An Idea

Two fish swam past one another. One turns to the other and says:

“The water’s nice today isn’t it?”

After a few minutes the second fish thought to himself:

“What’s water???”

Ideas are valuable. Ideas are the birthplace of innovation, entrepreneurship and value creation.

The problem in today’s world is that many ideas go unquestioned for so long that we forget that we can even question them. The fact is that opportunity surrounds us all if we only take a closer look and examine things a bit deeper.

In this respect we’re all swimming in opportunity, but just like that fish we may be blind to it.

There’s another problem. New ideas, heterodox ideas, the ones that at first instance seem a bit weird are often dismissed too quickly. They aren’t allowed to grow and mature, because just like anything else, ideas change over time and often get better.

So the key is to not only question what already is, but allow new ideas a chance by not interrogating them too much, but exploring them fully.

Ideas Come First

For some reason there is a notion that “science” generates ideas, that science provides the means to bring about spectacular new innovations.

But, it isn’t and never will be.  Science is a method to prove or disprove a theory.  The theory or idea itself came from a person who had a hunch.

I sometimes tell my patients a story about stomach ulcers.  It used to be thought that ulcers could never be caused by bacteria living in the stomach.  The whole scientific community found it preposterous that an organism would be able to live in the stomach and cause ulcers to form.

An Australian doctor had the complete opposite idea.  He had the idea that a bug* could indeed cause stomach ulcers and that a simple course of antibiotics could prevent people needing more invasive operations and reduce the chances of people developing stomach cancer if promptly treated.

“everyone was against me, but I knew I was right.” – Dr Barry Marshall

He used the scientific method to prove himself right – by infecting himself with the bacteria and treating himself.  He went on to win the Nobel Prize in medicine for his work.

How To Know If You’ve Got A Good Idea

I can’t figure out how to develop ideas.  Phrases such as “solve a problem”, don’t quite seem to do the job.

The reason is that “problems” aren’t clearly defined.  Problems – the type that actually matter and are therefore the most valuable are fuzzy and yet to be defined.  So framing a problem in and of itself is very difficult.

The other thing is that to really solve a problem requires you to have an opinion, a view of how things are or should be.  Like Dr Barry Marshall, you need to develop a point of view and then have the balls to stick by it and see it through to the end.

This is very rare indeed.

It is very rare to meet someone who has thought deeply about an issue and come to a conclusion which is unique and well thought out.  Most people not only allow others to define the discussion or the problem, but they rely on other people to provide the solution and thought process behind the reasoning.

I have noticed that if you do have an idea, the best way to figure out if it is a good one, is to put it to the test.  Implement it in the real world and see what happens.  It won’t be perfect and it will get altered, modified and changed** as time goes on and as it comes into contact with resistance.  But if all the signs point to the idea being robust then you owe it to yourself and the world to see it through.

*Helicobacter pylori

** There is an idea called “Hegelian Aufheben” which says that when some ideas come into contact with an opposing idea it is not destroyed.  Nor does the original idea destroy the opposing idea.  There are situations where the opposing ideas enrich each other and they both get better, stronger and more robust.

What Your Mother Can Teach You About Sales

(Before I tell you this story, I would just like to say a big thank you to my mother.  She’s really an amazing woman and this is just one of the many indirect lessons she has taught me over the years.)

I had a crisis of confidence before I started medical school.  I nearly didn’t go.  I don’t know why, but at the time I felt that perhaps I wasn’t meant to be a doctor , that there may be opportunities elsewhere which could be better.

My mother knew that I wanted to be a doctor since I was very young and knew what was best for me.  When I was having doubts about going to medical school she said:

“You’re going to medical school!  Or you’re not welcome in this house!”

OK, sounds harsh, but it really isn’t and I am eternally grateful.

I really did want to be a doctor since I as far as I could remember.  And now as a doctor, I am very glad I chose this path as the work is continuously interesting and challenging.

The point is that my mum cared about me.  Like, really cared.  She cared so much that she cut through the BS and basically just said “you’re gonna do it, or else!!”.

Interestingly enough, this is the best way to sell as well.  This overly caring yet demanding attitude is how you approach customers and prospects.  Sales people usually try to persuade prospects to do things for the wrong intentions; money and commissions.

But the approach and the mindset that works is:

“You are going to use my product or else!  Because I know what’s good for you and my product will REALLY REALLY make your life way better!!!!”

As a doctor, sometimes I know that a drug that I am starting my patient on will basically save his or her life.  There better be a good reason to not go on the medication, otherwise I’m not letting you get out of my office without a prescription!  I know what’s good for you!

As a salesman, I have the same attitude as this.  I know my product will really enhance my customers life!  As a result I have no issue with demanding that they sign up and start using my product.  I care so damn much, that I’m not leaving until they’re signed up!

If You Keep Doing More Stuff, You Will End Up Poorer, Less Healthy And Less Smart

Subtraction

I would say that around two-thirds of the patients I see in my clinic every day have problems related to something that they are choosing to do.

Chest infections caused by smoking.

Back pain as a result of sitting down all day and even after work.

Diabetes due to poor diet.

I seem to be locked in an eternal battle with my patients. I am continually trying to get them to come off of unnecessary medications, stop taking part in harmful habits and to stop taking antibiotics for viral infections.

Patients on the other hand come to me to take yet another pill for their ailments, seek yet another additional action they can take part in so that they can continue taking part in harmful habits.

I have come to realise that we humans find it much harder to subtract something from our lives than to add something to our lives.

It is easier to take a pill for high blood pressure than to stop doing the activities which has caused the condition.

It is easier to inject yourself with insulin than to stop eating processed foods.

I find it ironic how we take medications, often to mask our problems, which in turn leads to more problems down the line. It is clear that if we were simply to stop doing the harmful activity in question, instead of adding something new into our lives then we would benefit a lot more in the long run.

This got me thinking….

I have noticed that subtracting things from your life more often than not, leads to much greater gains than adding more stuff to it.

This is the type of logic that doesn’t make sense in a class room, but is empirically true.  Say for example you were tasked with building a wall.  In a maths book if a team of three people worked hard for 12 hours a day, you would be able to calculate how quickly each portion of the wall could be built.  Therefore if twelve people were put to the same task who could work at the same rate, you wold expect this team of people to build the wall at four times the speed.

In reality, if you were put in a team with eleven other people, with all the arguments, the organisational problems, the egos etc, it is likely that the wall would take much longer to build.  (If the government were put in charge with building the wall, it is likely that the wall would never get built.  I am sure there would also, at some point be allegations that the wall can be considered discriminatory against blacks/women/immigrants/insert a poorly defined group of people here…..)

I’ve been thinking of three examples in particular which I want to write about.  These three examples have given me more mental energy, made me fitter and made me financially better off.  I’m sure that these principles and concepts can be applied to anyone’s life.

The News & Social Media

Over the last couple of months I’ve stopped reading and listening to the news.  I haven’t used any social media since 2012 when I got rid of my FaceBook account, so I thought I was being smart by only using the Internet for learning, business and keeping up to date with the news.

It’s been an odd sensation since I stopped reading the news. I used to wake up in the morning, grab my smart phone and flick through a bunch of new sites. During lunch time I would revisit these sites to see if anything else was going on. I’d probably check again in the evening time at some point as well.

In total, I wasn’t actually spending much time a day reading and consuming news, but it did strike me at some point that I was not learning or gaining anything by reading it. This particularly hit me when I asked myself the question; “If I read last weeks news today, would I have missed out on anything at all?”. It became pretty obvious to me that the news is largely garbage.  In this respect it’s very similar to social media; It’s designed to cause an emotional (negative) reaction, it’s designed to suck out time and attention from its readers and it’s designed to keep you coming back for more for a quick dopamine hit.

At first I didn’t notice much of a difference in my life.  However, after a couple of weeks I felt a massive difference in my mind.  I found that my mind just had to deal with less noise.  I could stay focused on things that really mattered to me for much longer and I had much deeper insights about my startup due to the extra mental clarity.  In particular, my mornings now just feel much more positive and better.  It’s nice to not be bombarded with scare stories and the worlds problems first thing in the morning.

I now go to check out new sites just once a week.  And when I do visit these sites, I have noticed that I only read a tiny fraction of the stories, as most of it really is just non-stories aimed at getting you to have a negative emotional reaction.

There really is a case to be made about stopping oneself from visiting web sites which are known to be damaging to overall well-being and which we all know distract you from doing what you really want to do with your life.

Really worth a watch if you don’t agree with what I’m saying, because it seems that the ex-president and a previous executive working at FaceBook both agree.

Losing Weight

Here’s an interesting one.  Why is it that when people think about getting fit and healthy they immediately think about exercise*?

Why is it that people think about exotic diets?  Avocado and poached eggs on rye bread anyone?  Or how about a gluten-free, vegan “cake”?  No thanks, I don’t like to eat sissy ass food.

I think that it comes back to adding more things to your life, because it’s easier and somehow it seems “more right” to do something new when an existing diet isn’t providing results.  However, the reality is that subtracting bad foods from your life is actually the easiest, best and the most realistic way of losing weight for the majority of people.

Food is such a personal thing.  I wouldn’t expect anyone to enjoy my diet as much as I do or stick to my diet.  The food we all enjoy is likely a combination of social, cultural personal influences.  And it’s silly to think that you can adopt a random persons diet, be able to stick to it and enjoy it for the rest of your life.

Alan Aragon is a well-respected nutritionist who has coached many superstar athletes, including people like Pete Sampras.  The first chapter in his excellent book was: “What if Everything You’ve Been Told Is True?”.  He was trying to point out that for the most part, we all know what healthy food is.  We all know that a chicken breast is healthier than a french fry.

Here’s how to subtract food from your diet.  Some of my patients with a clinical diagnosis of diabetes have managed to completely stop their medications due to this simple method.

  1. Make a list of foods you enjoy eating, that you currently eat.  It’s very likely that there are a ton of foods that you eat that you know are healthy and that you can eat more of.
  2. Eat more of these foods!
  3. Eat less or get rid of the foods you know are unhealthy.
  4. Keep the healthy foods stocked up and get rid of the unhealthy foods at home to make sure you’re not tempted to just have a quick bite of something unhealthy.
  5. Eat healthy foods for 80% of the time and enjoy bad foods for 20% of the time.  The easiest way to do this is to be looser with your diet for one or two meals over the weekend.
  6. Enjoy the weight loss!

One very easy way of knowing if a food is healthy is if it is a single ingredient food that you can point at and name what it is.  For example: “That’s a piece of fish, that’s a potato”.  If you can’t name the food in single ingredient terms then it’s likely not healthy / is calorific.  For example bread and pasta are made up of lots of ingredients – eggs, flour, milk etc.  When foods are processed like this, they become calorically dense and usually end up being pretty bad for you.  For example, two slices of bread is usually 300-400 calories, which is the same as eating 400 grams of boiled potatoes.  Meaning that you would struggle to eat enough boiled potatoes to put on weight.  Single ingredient foods by their very nature have a comparatively small amount of calories for the quantity you can eat!

Subtractive Business Ideas

It never ceases to amaze me how good business ideas all seem to be subtractive.  I have noticed that my own healthcare business is subtractive by its nature, which may go some way to explaining why it has so much traction in such a short period of time.

This is what I mean by subtractive businesses / technologies / services;  They make life simpler and easier than before.  They uncomplicate processes and procedures.

Let’s take Google.  What did people do before Google was around and people needed information?  The used to go all the way to the library and go through books trying to find that single piece of data that they were looking for.  Or they would go and have a look at their own books.  Google is subtractive in that it has massively subtracted the effort needed to find data and it has made it much simpler to find the information that we’re looking for.

Uber did the same thing.  At the click of a button a taxi will appear.  No more trying to find the number for the local taxi firm, no more trying to figure out what the address of your pick up location is, no more wondering how much longer you have to wait for your taxi and no more worrying about having cash on you to pay the taxi driver.

Amazon.  At the click of a button you can order most of the commodities that you used to have to make a trip to the store for.  At the press of a button your chosen item will appear at your house in a day.

When most people try to think of what the future will look like they start to think about flying cars, talking houses and electrified pants.  Most people take the same perspective when they try to come up with new business ideas.  They start to have ideas which are “additive” instead of “subtractive”.  The best business ideas always go more along the lines of “There is this problem, which I could solve in a better and easier way, which people will give me money for.”

If we look at the successful businesses throughout history and the businesses which are going to be big in the future they have been and will be subtractive in their nature.

*Unless you are an Olympic athlete or a marathon runner, going to the gym and working out really won’t burn many calories at all.  Any fit person will say something along the lines of “abs are made in the kitchen” or “80% of results are from diet”.

This Is Why You’re Wrong About The Future Of The NHS

The large majority of the public don’t know anything about health and therefore healthcare provision.

The majority of journalists and politicians who write and speak about the NHS don’t know anything about working in healthcare and therefore the realities of delivering healthcare to actual patients.

If these two statements are true, then it’s safe to say that most people don’t have a real grasp of the actual problems faced by modern healthcare and where we’re heading.

What You’re Told

The public discourse always revolves around the same lines.

The left always ask for more funding as this would provide the public with more doctors, more hospital beds, more access to cancer treatments and so on.

The right, while not necessarily for privatisation, generally don’t like the idea of paying ever more taxes when the are so many inefficiencies in the healthcare system, when the country has a lot of debt and when people (immigrants etc) who they deem should not have access to the NHS are using up its resources.

Here’s the thing. Both of these stances are not addressing the problems the NHS is facing.  The demand in healthcare has been growing at an insane rate (some estimates state that healthcare demands have increased by 50% over the last decade) and will continue to increase. Therefore if we were to hypothetically provide all the funding needed to provide optimal healthcare for everyone and we were able to satiate this need right now, we would still end up in the same situation as now just a few years later.

It is important to realise that no country or system in the world has managed to solve the problem of healthcare provision.  All healthcare systems around the world are facing imminent disaster as the demand is growing at such a fast pace, so to say that either providing more funding or reducing inefficiencies would make much of a difference is wrong.

Re-defining The Question

It is often said that if you are given an hour to solve a problem, that you should spend the first fifty-five minutes defining the problem.

I think instead of asking the question: “What can the NHS do?” a better question would be “What should the NHS do?”.

The NHS is treating people mainly for conditions which are a result of poor lifestyle choices. Diabetes, hypertension, COPD, cancers, osteoarthritis (due to being obese), anxiety, depression and so on are all largely due to poor lifestyle choices. If hypothetically the NHS had all the money in the world, we would still end up with a society of over medicated diseased, unproductive people. Is this what we should be aiming for?

The fact is that the only solution for the future of health is not new technology, AI, new medications etc to treat the ill, it’s actually getting patients to take responsibility for their own health by leading a healthy lifestyle.  The only way to meet demand is to reduce demand, by reducing the number of ill people.

The problem with this solution is that it puts the onus of health back on patients.  I cannot see any politician or person in power really trying to push for this.  The backlash would be career suicide.  There would be a public outcry if this was talked about seriously.  I would imagine that a lot of patients would start to blame their circumstances for their poor lifestyle choices and demand that the government take responsibility and provide support for patients to make sure that they don’t develop chronic diseases.

This leads you to think that perhaps we shouldn’t be asking “What can the government do for public health”, but we should be asking “What should the government do for public health”.  This is where the debate needs to be.  How much personal responsibility should we all take for our own health?  And what would this type of society look like?

Things Your Doctor Can’t Do…

Maybe one day I’ll hang this list in the waiting room of my clinic:

  • I can’t cure your cold 
  • I can’t give you antibiotics for your cold
  • I can’t give you antibiotics for your flu
  • I can’t give you antibiotics for your diarrhoea of two days 
  • I can’t give you antibiotics for sinus congestion
  • I can’t give you morphine for your back pain
  • I can’t cure your back pain if you don’t lose weight
  • I can’t help you lose weight if you don’t eat right and exercise
  • I can’t help you with your diabetes if you don’t lose weight, exercise and eat right
  • I can’t help you with your high blood pressure if you don’t lose weight, exercise and eat right
  • I can’t help you with your chronic pain if you don’t lose weight, exercise and eat right
  • I can’t help you if you lie and say you are exercising and eating right
  • I can’t help you with recurrent chest infections if you keep smoking
  • I can’t reverse your Lung Cancer which was a result of your smoking
  • I can’t cure your depression / anxiety if you aren’t trying your very best to lead a life based on honourable work, forming meaningful social relationships, exercise and eating right