Life Isn’t Fair, But If You Don’t Get This Simple Point You’ll Always Be A Sucker

Life is very unfair.  As much as we all wish that the success we enjoy in life is a direct consequence of our well thought out actions and intentions, it probably isn’t.  If you were born poor in rural Bangladesh, could you still confidently say that your quality of life would be as good as it is now?

You’re not pretty enough, thin enough, tall enough, rich enough, you were born to poor parents, you went to a bad school, you were born in the wrong part of the country, you’re the wrong colour…This list of excuses is endless.  It’s undeniable that these characteristics and ones upbringing does indeed have a large impact on your life’s trajectory.

This post isn’t about “victimhood”.  Everyone is aware that you have to hustle to get ahead in life and that without hours of hard work, you simply won’t get anywhere.

This post also isn’t about being “stoic” and just accepting that you can work hard, toil away and yet still achieve very little in life.

This post is about how we can embrace the randomness and entropy that surrounds us every day and use it to our advantage.  In short, this post will teach you how to win at life.  But first, a few illustrations are necessary.

Estimated Time of Arrival

Google Maps has replaced my Sat Nav machine.  I don’t know when it happened, but it definitely beats using a stand alone machine.  I was particularly put off using stand alone Sat Navs ever since someone broke into my car to steal one!  The burglar probably sold it for £20 at the local pawn shop, but left me with a repair bill of £120 for my car.

A few days a week I make a 60 mile commute to my clinic to see patients and make sure everything is running properly.  Get in the car, put my phone in my phone holding thingy and set the destination; “Estimated time of arrival 10.30AM”, it says.

It seems that Google Maps and lots of other navigation apps try to figure out the “quickest route to destination”.  We’ve all probably had instances where we’ve put the navigation on in a familiar neighbourhood and have blindly followed its instructions, even though we just know that if we went our usual route we would have gotten to our destination quicker.

This minor gripe is merely annoying, but the worst kind of problem with Sat Navs is when we go on those longer journeys.  “Estimated time of arrival 10.30AM”, it says, but why is it that most of the time I get to my clinic a few minutes after the ETA?  The worst is when something unforeseen happens, such as an accident on the motorway and I end up at my destination an hour or more late!

Why is it that I never get to my destination an hour or more early?

In England we have roads called “M” roads, which are the largest roads with the highest speed limits.  We then have other major types of roads such as “A” roads and “B” roads.  As you can imagine “A” roads are the next quickest after “M” roads.  Interestingly enough, Sat Nav systems always tend to pick routes with “M” roads whenever possible.

This is an interesting way to get to your destination.  “M” roads are definitely faster, but if there is an accident, then you’re doomed to suffer hours stuck in traffic wondering why that annoying Audi behind you is driving so close when there’s clearly a traffic jam ahead.

“A” roads on the other hand have plenty of tributary roads.  Traffic jam?  No problem, just turn off and join another road and you’ll be on our way with a merely slight delay.

Satellite navigation systems are missing out on a trick in my opinion.  Instead of being able to pick the “fastest route” it should actually give you two options;  “Fastest route, but if something happens on the road you’ll be REALLY late” or “Slower route, but you don’t need to worry about being too late if something goes wrong.”

I wonder how many people would choose the slower route with less variability when it comes to important journeys such as getting to the airport on time to catch a flight?

The Doctor-Patient Relationship

When I used to work as an acute general surgical doctor, we used to quip that it would be more cost effective to carry out a whole body CT scan as patients were carted on to the ward.  Almost, like those body scans at the airport!  It certainly would have made our lives as doctors much easier if we could simply just get the scan done and see whether there was something worrying to operate on straight away, instead of having to sit down with the patient and get their history.

The acute surgical ward was a stressful place to work.  Patients got referred in by the Emergency Department or Community Doctors and then we had to assess the patients and figure out if they needed an emergency operation.

The problem on this ward was that it meant you would have to spend at least 30-40 minutes with the patient, listening to their story, taking blood tests and then you’d have to wait for several hours for the blood tests to come back.  Once the blood tests were back, unless it was an obvious appendicitis or cholecystitis, you would have to organise a CT scan.  If you consider that many patients end up staying in the hospital overnight at a cost of £400, only to be told the following morning that all the investigations were normal and that they can go home, then having a CT scanner placed at the door doesn’t sound like a bad idea as a scan costs around £100 per patient.

You might be thinking that all these tests sound totally unnecessary.  I would agree with you.  The problem in medicine is that when a patient gets referred to you by another doctor, the onus falls on the accepting physician to ensure that nothing is wrong.  In other words the buck stops with you.

What do physicians with this onus do?  Test, test, test!  Do all the blood tests under the sun.  Does this patient actually sound like she has a simple urinary tract infection which can be treated with three days of oral antibiotics?  Doesn’t matter!  We can’t risk it!  We must do all the blood tests which will make sure her bowels, kidneys, liver, pancreas, anaemia levels are all normal and if these all come back normal then she must have a scan of her abdomen as well (exposing her to more than 500 times the radiation of a chest x-ray) to just be safe.

How did medicine get this way?  There seemed to have been a simpler time in medicine, which I personally didn’t get to experience.  My father on the other hand reminisces about those times frequently.  “There used to be a time where doctors were respected and decisions were made mutually with the patient”.  I, unfortunately have been trained and continue to practice medicine in an era of litigation and suspicion.

The threat of litigation and the risk of potentially losing your medical licence with every patient you see causes you to practice medicine a lot more “defensively”.  Even if doing more is potentially harmful, it is often better to be seen to do something (which is defensible in court) than not carrying out an intervention (which is indefensible).  “We might as well as take out that gentleman’s appendix, just in case.”.  If you don’t take out the appendix and then it does turn out to be an appendicitis, then set aside a date for court my friend.

Is This a Good Idea??!!

“Is this a good idea”.  Every budding entrepreneur mutters those words.  Usually, so often that it drives loved ones near to the edge of sanity.

When they ask “is this a good idea?”, what thy are really asking is “will I make tons of money from this?!”.  Many entrepreneurs say ideas don’t mean a thing, but that the execution of the idea is the main thing.  I agree with this sentiment….to a certain extent.  If the person I’m talking to isn’t an action taker, then for definite it doesn’t matter what idea he has, because they’ll never do anything.  Ideas by themselves are meaningless.  But, if I’m talking to a really smart person, who consistently takes action, then yes ideas do matter.

The number of businesses is growing every year.  What’s interesting is how few are successful and how little money most businesses make.  I mean they’re all businesses after all and a lot of them do pretty much the same thing, but why is there such a large difference in revenue between them?

Why is Starbucks so profitable while that small cafe ran by that pleasant family down the road is struggling to make ends meet?

Or better yet, why will that coffee store never become the next Google?  Now obviously, Google are providing a completely different service, but what are the factors that set apart your average family run coffee store to an Internet company based in San Francisco?

The anatomy of a good idea goes a long way to explain whether an idea is worth pursuing or not.

The World Is More Random Than You Realise

The world is a very random place.  We as human beings are predisposed to create narratives to help us make sense of the world.  It gives us the feeling that we can predict the future.  Daniel Kahneman, the Nobel Prize winner, has written about how our brains are wired this way.

I remember when I was in high school and my music teacher played a piece of music to me.  It was a recording of a flute playing random notes, in a random order, with no time signature.  What was interesting about listening to this totally random barrage of notes was how my brain couldn’t help but construct melodies out of thin air.  It was the musical equivalent of “don’t think of a purple elephant!”.  Your mind will construct thoughts automatically and come to conclusions as a reflex.

Apart from my own anecdotes, there have been many studies which have proved how truly random the world is and how poor, we as humans are at predicting outcomes and making decisions.

Philip Tetlock, from the University of Pennsylvania made a landmark study: “Expert Political Judgement: How Good Is It?  Can We Know?”.  In this study he asked 284 political experts to make 80,000 predictions.  In the study he gave the political experts a topic to consider and then gave them three options to choose from.  He later looked at if the predictions were correct.

The experts turned out to be worse than random.  Meaning that if he had gotten a monkey to randomly pick an answer, the predictions would have been more accurate.  One of the reasons that expert predictors get it wrong so often seems to be a result of knowing too much.  Experts seem to over complicate their predictions by looking at too many factors and making too many outlandish correlations.

For business owners / CEO’s and entrepreneurs, the news isn’t too great either.  I love entrepreneur books and biographies of successful people.  But they do for the most part seem more like fairy tales, rather than scientific studies of success.  Which is fine if you’re into that sort of thing.  However, studies have shown that the strength of a CEO and the success of the company that they are running are not well correlated at all.

If CEO’s were really the rock stars they are made out to be in the popular press then there should be a direct correlation between the success of their companies and their skill level.  If you took a really bad CEO running a company in a certain industry and then took a really good CEO running a company in the same industry, you should expect to find that the better CEO’s company is always outperforming the one ran by the worse CEO.  But the correlation hardly exists!  If the correlation was perfect (i.e. a good CEO always producing the best outcomes and beating the competition) then the correlation coefficient would be 1.  In reality, the best estimates place the coefficient at around 0.3, which is only very slightly better than random!

My point is that skill and knowledge clearly exist, but the world is an incredibly random place.  Most people’s ability to make decisions affecting their future are random at best and worse than average at worst.

How To Not Be A Sucker

What do motorways, being an acute surgical doctor and good business ideas have in common?  One word: asymmetry.

Asymmetry means that there is an unequal relationship present.  To compound this, as the world is so random and unpredictable, you never know when the asymmetry is going to hit you and how much of an impact it will have in your life.

Motorways for example have an asymmetry in terms of getting to your destination on time.  Either you’ll be a little early, on time or if something goes wrong on the roads, such as an accident, then you’ll be extremely late i.e. an asymmetry is present here.

In the world of medicine / surgery, there is an asymmetrical relationship between the physician and the patient.  Theoretically if a doctor makes a mistake with any patient they ever see, they can lose their medical licence.  Patients may genuinely come to harm in some cases, however in the UK, the GMC (General Medical Council) have stated that over 90% patient of complaints / litigation made by patients is unwarranted and unfounded.  There is an asymmetry in the relationship as patients can make a complaint which may be false, but there are no repercussions if their complaint is found to be based on a lie.  Patients do not get any financial repercussions or penalties if their complaint doesn’t get upheld.

These asymmetries exist in a lot of different domains in life.  For whatever reason most people are blind to this and are unaware of such relationships.  But if you are aware of these relationships it will cause you to make better decisions.

The two examples we’ve talked about above are what I call negative asymmetries.  Meaning that if a random even occurs then it will make your life worse.  But, you can also use asymmetries to your advantage!

Take for example business ideas.  Good business ideas have asymmetries present which could result in exponential / unlimited financial returns.  Most business owners simply aren’t aware of these principles.  This is the reason why that small coffee store down your road will always continue to struggle and why that pleasant family will never be financially free – even though they could be.

I could speak a lot about great business ideas, but the two main principles in good business ideas are the ability to scale and detach your own time from your business.

Say that you open a coffee store.  Part of your business mission should be to put systems and protocols in place so that every cup of coffee is produced in the same way at the same standard, the store should always be cleaned in the same way up to a certain standard, the way items are procured and how much they should cost should be standardised, the way customers are greeted and treated should be standardised.

Basically every aspect of the business should be run with protocols in place.  This way, if you, the business owner decide to leave for a couple of months for a holiday, your business will keep on chugging along as usual.  In other words, you’ve created a system which is not attached to your time or presence – you’ve just created a money printing machine, which is exactly what businesses are meant to be.

If you can detach your time from your business, then inevitably you have created a business model that is scalable.  There is no reason why you can’t open up another coffee store usinng the exact same training protocols you have already created in your first store to expand your empire.

Business success is random as we have already demonstrated.  But, if you have a well thought out business which can be scaled then randomness can have a positive impact on your business and life.  As businesses which are designed to scale have asymmetrical returns then you could win big and be financially free.

In life if you don’t set yourself up to win and use randomness to your advantage, then you will always be at the mercy of randomness and asymetries.  You will always lose and be a sucker.

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“Disruption” Is For Fools

Every week there seems to be a news story on how an app has been developed to “disrupt” the healthcare industry.  I despise what this term has come to mean and as soon as I hear someone say it, I know I’m speaking with a fool.

“The Uber of Healthcare!”

“The Amazon of prescription drugs!”

“The Airbnb of social care!”

These ideas actually sound really good on paper.  The profitable business model has already been executed and refined in other industries.  So you just need to take the idea and implement it in a different industry and et voila, you’ll have a billion dollar business!

I can imagine the type of people who think that copying business ideas and implementing it in healthcare is a good idea.  Usually people in dark blue suits, rather than a hacker wearing a t-shirt.

I suppose there’s an aura of courageousness associated with carrying out a project that can potentially “disrupt” a given market place.  However, in my own experience I can see why these projects always fail and in most cases, fail really quickly.

What Is Disruption??!

Definitions are important.

Before “disruption” turned into a buzzword, it actually used to mean something completely different.  Nowadays, disruption means a piece of technology that’s designed to destroy a business or a business model.  The people who do not embrace disruption are accused of “protectionism” or not getting with the times.

“I can buy my groceries online, so I want to get all my doctoring online as well!”

This argument is obviously a non-sequitur.  But entrepreneurs in blue suits and the lay public are often incapable of critical thinking…

Disruption used to mean a piece of technology which would radically lower the price of a produced product.  For example, microprocessors allowed computers to get cheap and it allowed new businesses to flourish.  IBM had market dominance in the computer space by making mainframe computers.  They thought that microprocessors would have no significant effect on computers and so other companies came along and “disrupted” them i.e. other companies provided a cheaper alternative to mainframe computers and produced the Personal Computer.  Soon Microsoft made it their mission to “put a PC on every desk”.  The rest is history.

There is a big difference between this kind of disruption and the kind of disruption which is always talked about in the press.  Microsoft didn’t think “we want to destroy IBM and the other evil incumbents!”.  In fact IBM was the company that (mistakenly, in hindsight) gave Microsoft the rights to produce the operating system for their own computer systems.

It is quite interesting that the companies which have actually “disrupted” industries successfully often go unnoticed and are not really thought of as “disruptive”.

PayPal for example disrupted the financial industry with their online payment system.  At the time the financial sector didn’t want to go anywhere near online payments as they feared that the amount of fraud would destroy them.  There was a gap in the market and PayPal took on the risk.  As they grew they figured out ways to lower their fraud levels and made it a profitable business.  Peter Thiel (one of the founders of PayPal) went on to say that although they disrupted the sector their company was welcomed as they actually created a lot of business for companies such as VISA.

There’s a pattern here.  True “disruption” isn’t about creating a lot of noise and trying to destroy particular companies or industries.  It’s about creating technology which creates a meaningful impact in the world.  If certain incumbents fall by the wayside as a result, then so be it.  But that shouldn’t be the mission of the company.

Liberalism & Conservatism

I thought that an addendum would be apposite here.

Recently I’ve been thinking quite a lot about conservatism vs liberalism and its role in entrepreneurship.

I have found in my own experience that a lot of tech entrepreneurs / people who want to “disrupt” industries are more of the liberal type.  These are the t-shirt and jeans types, with strange facial hair and never more than a meter away from an Apple product.  Liberalism seems to go hand in hand with creativity.  Being open to new ideas, new ways of doing things, criticising old ways and paving the way for new ways of doing things is what liberalism is all about.

It’s easy to see why these people would find the idea of “disruption” quite romantic and heroic.  “Imagine if we lived in a world where these bureaucratic systems were not in place.  Technology, could supplant all of these unnecessary  systems.”.

Wait, so earlier in this post I was complaining about people in blue suits and now I’m complaining about people in t-shirts and jeans?!  Well, the worst types of entrepreneur are those in blue suits who are trying to be liberal and trying to act like they are innovators, when actually they’re just people looking to make a buck.

Like so many things in entrepreneurship, it seems to me that the perfect entrepreneur is a mix of liberalism and conservatism.

Entrepreneurs who embrace the past, work with well established institutions and companies, but are also able to embrace the future and lead us to the new world are the real deal.

Peter Thiel to me encapsulates the perfect entrepreneur.  He supported Trump, has quite a conservative outlook, but at the same time is working on AI and has successfully disrupted the financial sector.  He also wears suits, but with his top button undone…Perhaps the best dress code?

Artificial Un-Intelligence

Before I started my tech startup Artificial Intelligence (AI) really wasn’t on my radar.  I was somewhat aware of autonomous driving vehicles, but apart from that I didn’t see how AI was going to have an impact in my life.

Even now when I meet with other tech entrepreneurs, the discussion surrounding AI often causes me to go quiet.  I think that part of the reason I go quiet is that people talk about AI as if it has already happened – and if you’re not involved in the scene then you’re missing out.

Even the almighty Elon Musk often talks about how AI is one of the greatest threats to mankind.

So, what reason do I have to think AI isn’t really a big deal?  After some further reading over the last few months I think there are a few main reasons why I am not convinced of the AI apocalypse just yet.

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Robot Apocalypse!!!

Defining Intelligence

What actually is intelligence?  I think this is a good starting point in this discussion.

Intelligence as we currently know it has three components.  A stimulus which results in >>> a process >>> which results in an outcome.

As a doctor, I have a pretty good overview of how this type of response architecture works in humans.  If for example we see a cat, the image of the cat is focused by our eyes (the lens, cornea, small muscles of the eye etc) and an image is projected on to our retina.  The optic nerve then transmits the image to our brain.  Having studied some basic neuro-science and neuro-anatomy in school, I  can reassure everyone that we have no idea what happens with the said image at this point.  Sure, we know some of the pathways that the neurons in our brain use to transmit the image around.  If for example you have a lesion at the optic chiasm then part of the image we see of the aforementioned cat will be missing.  But, we have no idea how our brain interprets the image and results in the outcome i.e. what we do next.

In other words we have no idea how the image of the cat results in us dismissing the cat or going to pet it, or shouting at that damn cat to get off our car!

There is another factor in this architecture.  The “outcome” is different for all of us.  Humans have free will and agency.  We are not simple creatures with certain inputs and outputs.  Someone may see the cat and get terrified as they suffer from ailurophobia, someone may feel sorrow as they remember their deceased pet cat from childhood.

Human intelligence is very nuanced.  In actual fact this simple observation was only recently acknowledged by the scientific community in the last few decades.  Previously scientists had the view that intelligence was simply: Input >>> Output.  Meaning that a certain input would result in certain predictable output.  This was the “Behaviourist” point of view which has been superseded by the more nuanced view of intelligence discussed above.

The way we learn language is another example of the nuances of human intelligence.  It’s quite interesting that infants and toddlers pick up the prevalent language around them so easily.  If you think about it, when you are born there’s a lot of noise.  It must feel like a complete sensorineural attack for babies.  In this environment how is it that they are able to pick out words and start developing speech?  It has also been shown that infants are able to pick up languages and start speaking fluently despite not hearing all the words in any given sentence.  So they are able to pick out words and work out the syntax with ease.  On top of this – if they have started to develop a language, they can happily ignore foreign languages as they can tell that this is not their language.

What this example of learning language implies is that humans have an inherent ability to learn languages.  There’s something within our brains that wire us to pick up languages and communicate with one another.  This was a ground breaking insight by the linguist Noam Chomsky.  He scientifically showed that the principles underlying the structure of language are biologically determined in the human mind and hence genetically transmitted.

Again, how we are genetically determined and how the human mind works is largely still a mystery.

Coming from a bilingual background myself, I do find it interesting how I have managed to learn two languages while growing up and have never mixed the two up or gotten them confused with one another…

Artificial Behaviorism

So now that we have a basic understanding of what intelligence actually is, what is the state of artificial intelligence as we know it?

AI as we know it right now is basically statistical analysis.  It sticks to the (now-defunct) behaviorist view point that input >>> output.

Give a computer a bunch of inputs, feed it a ton of data.  The computer can now process all that data due to increasing RAM and CPU power.  Then the computer will give you an outcome.

As a result people like IBM can analyse the chess moves of every chess game ever played, feed it into a computer and the computer will make moves which will lead to an outcome that will mean it is likely to win.

Or you implant a computer into a car which can analyse its inputs (images of the environment, the behaviour of surrounding cars etc) and the car will drive and manoeuvre so that you don’t crash.

In other words:  Data in >>> Statistical analysis >>> Outcome.

This is not intelligence as we know it by any stretch of the imagination.  This is statistical analysis and has been touted as a revolution since before the 1960s, but has yet to make much of a dent in the world.

Note that in the cases of chess playing and driving, that it is the humans who have already done all the interesting work.  It is the chess masters of years gone by that the computer then goes on to analyse.  Without the human input there is no useful output.  So, the statistics which are analysed to lead to a useful outcome are always created by humans.

This technology may be useful in certain fields.  It does seem that work which is mundane, doesn’t require much human input, creativity, thought etc can be automated.  However, let us not confuse “automation” with “artificial intelligence”.  I think automation will be massively disruptive to the world of work, but not the type of creative work that matters in the world.  Not the type of work where human interaction takes place, where empathy is required, where original thought takes place.

Statistical Analysis & Big Data

There are a ton of startups and established companies who have been going on about big data for years now.

This is the stuff that people in Silicon Valley are always talking about; “Imagine if we could create AI and allow it to analyse all the data on the Internet”, or “Imagine if we could get our hands on patient medical records and allow AI to analyse all that data”.

For some reason people think that statistical analysis of large data sets will reveal new compelling information and automate and improve how, for example, medicine is practiced.  It is thought by pseudo-scientists that medicine is not scientific enough.  “Maybe if we analyse all the data, medical records, blood work, etc then we can detect diseases before they have even occurred / just about to occur!”.

Well the problem with statistical analysis to reach a conclusion only works when you are looking for one specific outcome.  For example, the NSA do this the right way.  They analyse data to figure out one thing: “Should we be suspicious of this person or not?”.  When it becomes more complex than a yes or no answer we run into trouble analysing data-sets.

Let’s look at medicine again.  If we look at a patients whole medical record and run it through a ton of statistical analysis and find correlations, you will draw more and more false conclusions.  It will look like an exponential curve:

 

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Let’s say that data points run across the X-axis and the correlations found run on the Y-axis.  It’s clear that the more data you feed it the more false meaningless correlations you will reach.

In fact you’ll get very random correlations which are meaningless such as the consumption of chickens being correlated with the amount of US Crude Oil being imported:

chart

 

Skeptical Empiricism

In fact this is only the beginning of real science and knowledge.  Medicine is an interesting topic as it treads the line between science and real world skeptical empiricism.  What I mean by this is that if you get something wrong in the world of medicine then it can cause real patient harm.

Medicine over history has made progression with continuous experimentation and then observing the results of a given treatment or intervention.  It doesn’t work the other way round.  You can’t come up with a statistical correlation that says something along the lines of; “If you eat eggs, then you will get diabetes” and expect it to be at all meaningful.  Is it because people who eat eggs are also more likely to smoke and not exercise?  Is it the actual cause of diabetes?  Does it affect all populations?  And so on.

In fact statistical analysis such as this is likely to cause more harm than good due to increased interventionism being carried out which themselves will carry a larger list of adverse effects.

So in effect only a very foolish person would take any kind of correlation seriously and change their clinical decision-making due to random correlations, over the already well-tested evidence based empiricist medicine which already exists.

In effect, I don’t think that AI right now is anywhere close to what people have been claiming it is capable of just yet.

Healthcare & Volatility

Working At Scale

General Practice / Primary Care has been around for a long time in the UK (since 1911).  It is currently going through a massive transition due to funding cuts by the government, the pressures of having to deal with today’s needy patients and the increased work load being transferred from Secondary Care to Primary Care.

General Practice was traditionally provided by small Practices – often one or two doctors looking after the local community surrounding their surgery.  This model of care which has survived over 100 years, is now being radically changed.

To deal with the modern landscape there is a push by the government for general practice doctors to combine to create “MCPs” and “ACOs”.  These are large organisations  which have a very different way of providing healthcare.

Traditionally, patients would register with their local GP and over the ensuing years they would build up a real relationship with their Family Doctor.  This would allow GPs to provide a holistic approach to the care that was given.  Having this connection with patients of course made it a very cost efficient way to provide healthcare as patients could be managed in an appropriate way, rather than the secondary care approach which entails carrying out a barrage of investigations and providing a ton of treatment in a cookie cutter fashion.

This model of care is still proving to be very efficient today – over 90% of patient contact by the healthcare system is carried out by primary care and they are only provided with around 7% of the NHS budget.  That’s pretty good bang for your buck!

The new care organisations which are currently being created are turning GP surgeries into outpatient hospitals.  They will be staffed by “Salaried GPs” who will work in them on a rota basis (much like hospitals).  They will increasingly carry out the outpatient services traditionally ran by hospitals.

The hypothesis behind this shift is that “working at scale” will reduce costs for the healthcare service as a whole, as more conditions will be able to be looked after in the community.  Instead of being referred to the hospital for that cough, you will instead be seen by a GP with a special interest in respiratory medicine and instead of seeing the GP on your first consultation, you will be seen by an advanced nurse practitioner or a trained Pharmacist.

Sounds great!  Patients have more access to healthcare and more healthcare can be delivered at a lower cost.

However, the problem with this new model is that it is just a hypothesis, which is untested and since its inception has not provided the benefits that were promised.

The Lindy Effect

The reason healthcare is so hard to provide and also why it is so hard to change is because it is incredibly complex.

The NHS has to deal with the whole of the UK population and try to provide acceptable care to all people regardless of their backgrounds, it has to deal with the whole gamut of human diseases, psychological problems, social problems, economic problems, governmental initiatives and rules, different vested interests, market rules, changing demographics and so on.  It also has to provide an increasing amount of treatments, social care, investigations, operations etc.

The Lindy effect is the concept that the future life expectancy of a non-perishable technology or idea is proportional to their current age.

For example, the Bible has been around for 2000 years, it is likely – due to the Lindy Effect – that it will be around for another 2000 years.  It is not certain, but it is a statistical likelihood.

The reason the Lindy Effect is so potent is because it means that an idea or a technology has been put through the test of time and has had to have been through a whole host of iterations and complex challenges.  This increases and verifies its robustness.

One can think of it as a type of natural selection.  Put a piece of technology through a whole bunch of stressors, environmental changes, cultural changes, economic pressures and so on.  The technology that survives can continue to exist.

Time also allows us to be as sure as possible that the piece of technology in question works and is as devoid of as many side effects and adverse outcomes as possible in comparison to an alternative solution*.

Exposure To Volatility

Good systems are exposed to volatility and are allowed to thrive or die.  Primary care as we know it today has been exposed to a whole lot of volatility and as such it is a very robust and dependable system.

In the UK the government provides each GP Surgery with a certain sum of money each year.  This mainly depends on the number of patients that are registered at the practice.  With this sum of money the doctors in that surgery have to provide all the healthcare needed for their group of patients**, pay staff costs and run their business.

So in other words, for a limited amount of money, the NHS GP has to provide an unlimited number of appointments and services to meet their patients needs.  Any business-type would run away from this type of responsibility as unlimited supply is not logically possible.  However, this is the value that NHS patients are getting.

Each patient in the UK receives only around £90 of funding from the government.  This is generally less than people spend to insure their pet dog.

So in effect Primary Care has had to survive each year under very difficult conditions.  If demand and costs go up, GPs make less money.  If GPs can’t work efficiently, they lose their business and contract.

Currently, it is a robust system and works incredibly well – no one can deny this.

Denial of Statistics & the Removal of Volatility

The governments proposal to make general practice work at scales denies the existence of the Lindy effect (i.e. it dismisses statistics as a whole).

The fact is that statistically speaking, coming up with a whole new system of providing healthcare in a boardroom is incredibly naive and there will be a ton of unforeseen consequences.  I can guarantee that this will be at the detriment of patient care.

This type of “forward thinking” is a very “MBA type” of thinking.  It is all based on hypotheses  (aka guesses) by people in dark blue suits.  It ignores the existence of complex systems, second and third order effects which are not predictable no matter how smart you are.  It is the opposite approach to how successful businesses get created in the first place i.e. test a hypothesis and if it works then scale.

Not only is this new model of care worrying from this perspective, but it also removes the volatility faced by Primary Care currently.

As noted above, Primary care is exposed to the realities of having to provide care in a cost efficient manner.  Recently, as the potentially infinite workload is increasing alongside an increasingly finite remuneration, GPs are leaving the UK to work elsewhere, work in the private sector or retiring early.  In effect, the relatively reduced amount of funding is causing General Practice to fail.  This is volatility at work and indicates that something should be done to continue to provide good healthcare.

These MBA types have come up with a solution which they think avoids simply funding general practice adequately.  Their solution is to “work at scale” which involved GPs pooling resources together in the hope that this will somehow reduce costs.  A more logical process would have been to observe that General Practice is incredibly robust and cost efficient and simply increase funding.

These large “MCPs” and “ACOs” usually have over 70,000 patients on their registered lists.  These organisations if they fail economically and are not efficient will simply not be able to go out of business.  The government will have to intervene and bail them out as otherwise whole regions of the UK will not have healthcare provision.  Inevitably in the long run this will cost the tax payer/the government more than if they just persevered with the current system and funded it properly.

With these new systems as they will not go out of business, inefficiencies will increase.  Just think of the inefficiencies faced in large hospitals and it becomes clear that these large MCPs which resemble hospitals will face the same issues.

People In Blue Suits

This lack of understanding of the Lindy Effect, the lack of understanding of healthcare and its complexities by MBA types in their dark blue suits fares poorly for the future of the NHS.

It is astounding that such important issues are left in the hands of people who simply have no idea of what needs to be done.

In the mean time it is the front line staff – nurses, pharmacists, administrative staff and patients themselves – that will have to bare the brunt of increased risk, uncertainty and poorer healthcare outcomes.

*Thinking of religion in this way is quite an interesting thought experiment.  Could it possibly be that certain aspects of religion have benefits which we are unaware of, but due to the very fact that they have lasted for so long have untold benefits?

For example, many religions recommend fasting.  Only recently are the benefits of fasting being demonstrated in scientific research.

** In the UK, GPs are not able to close their patient list.  As a result anyone can go to a GP surgery in their region and register as a patient.  GPs are swamped with work and would rather close their lists, than to have more patients, more revenue, but not be able to provide good healthcare.

NHS Startup Part XVII – The End

Gosh, it’s been a long time since I posted about my startup.

I’ve decided that this will be the last blog post which talks about the minutiae of my startup and the challenges a new company in the healthcare scene has to face in the UK.

The reason this will be the last update is because the specifics of my startup are not helpful to other entrepreneurs / healthcare innovators out there.  The fact is that everyone will have to traverse a terrain which is different and face challenges which are different.  This I have come to realise is why so much advice surrounding entrepreneurship is so general.

“Solve a problem”

“Expect the unexpected”

“Provide value”

“Make connections”

These platitudes may seem clichéd and obvious, but they are cliched for a reason – it’s the truth and giving advice more specific is often not relevant or helpful.

Having said that here’s another update!

I Am a GP Partner Now

GP partners are owners of clinics in the UK.

This is a very privileged position I am in.  Basically I now have a test bed to test my application in.  I also have an allocation of money from the practice to keep building my app.  So, I am very lucky indeed to be have been given such a massive opportunity.

This is the best position a founder could be in!  Solving your own problem with outcomes which will be beneficial to yourself validates your idea for a business and ensures that at least one person will benefit from your product or service!

Keep in mind that 88% of founders fail because they fail to make something that people really want and will pay for.

To Spread or Not to Spread

The app is being used in a few test beds now.  As such I haven’t pushed for it to go into more and more healthcare settings.

The reasons for this is that the app has potential to become really killer.  But I need time to build the rest of the necessary features.  This will take 8 months or so.

It may seem risky to not keep pushing for it to go into more and more places, but there are a number of reasons why  think it’s a good idea to not spread to quickly in the healthcare space.

The first is that it’s very difficult to get into anywhere – but now that I am convinced that I will be able to get into more places, I need to make sure to not blow it by providing bad services or a crappy product.

The other reason is that when you’re creating enterprise software, the app itself is a small part of the whole business.  This is another reason why it’s a bad idea to learn to code just to make a business.  The fact is that people don’t just pay for an app (particularly in healthcare), but infrastructure, support, insurance, certification, governance etc etc.  Also, as you provide software to more settings and businesses, more code needs to be written to provide infrastructure for billing, handling new data and new protocols have to be written for implementation.  The legal implications and finances also becomes a whole lot more complicated.

Looking at it this way, I’ve figured that the best way to go forward is to really make an awesome product, get sales lined up and then launch in more places once we’re happy that we can deliver something remarkable.

The Future

The future looks good at this point.  I’m solving a real problem, we have customers, the scope of the app could make a really positive change for both patients and healthcare providers.

There will be plenty of challenges up ahead.  However, just because I’m not writing these in-depth updates doesn’t mean much for followers of the blog.

The fact is that anyone who really wants to do what I am doing can just read my blog and follow me.  As the whole blog is about entrepreneurship and healthcare, people will learn a lot more by reading and understanding the general view-point of an entrepreneur than to follow all the details closely.

Because let’s face it, how many other people out there are GP Partners and creating software for the NHS?

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.