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”.

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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?

Second Order Discovery

Introduction

Second order thinking is hard.  It’s not a natural way of thinking.

First order thinking refers to the most simplistic method of analysis.  You can think of it as a form of thinking that most people engage in.  As most people have the same thoughts, which are automatic and go without any questioning, they come to the same conclusion.

Second order thinking is much rarer and only a small subset of people sit down to think about topics deeply and then come to conclusions which may be different from the majority.  Obviously, if you have unoriginal thoughts, then you will have the same actions as other people which is why second order thinking is so important.

An example of first order thinking would be how most of my patients think.  “I am depressed, therefore I need medication.”  Second order thinking is much deeper and takes into account a lot of different important aspects.  Second order thinkers may start to question their role in society, the role of society itself, value creation, what they value, being valuable, family, relationships with family and their neighbours and so on.  These people end up coming to conclusions which are different and most of the time (especially when it comes to more complex topics) more correct than first order thinkers.

I want to write today about second order discovery.  Something that I haven’t seen written about anywhere.  However, I think it is very relevant to business and entrepreneurship.  As this essay itself is a form of second order thinking (although much of it is derived from empiricism) it is quite axiomatic; reading the whole thing is the only way that you will be able to understand what I am trying to say.

Innovation & Entrepreneurship

There is a widespread misconception that “innovation” is the same as “entrepreneurship”.  It is not.  Many of the world’s most famous innovators died poor.  It’s not people’s fault that they presume “entrepreneurship” is the same as “innovation”.   These two terms are conflated by the popular press and in the public discourse.

However, if you look at the history of technological advancement, it is shocking to see how little entrepreneurship has contributed to it.  There is a very interesting page on the NASA website which shows the number of real life-changing innovations NASA have created as a result of space travel such as the development of artificial limbs and ventricular assist devices.

The reason entrepreneurship necessarily doesn’t lead to massive technological advancement is very simple: Entrepreneurs create businesses which have to be economically viable.  However, real impactful innovation most often occurs as a result of continuous government funding and experimentation by technologists in government institutions such as Universities.  The modern PC and the Internet for example arguably are the technologies that have had the most impact in the world in the last couple of decades.  These were both borne out of government institutions.  Once the technology is available, it’s up to entrepreneurs to then create products and services which the market will want to pay money for.

Note that also technological advancement and the discovery of its applications is always the result of random experimentation, serendipity and luck.  Most of the technologies we take for granted today, such as antibiotics were discovered by luck, not by design.  Indeed the technologies that NASA created are a perfect example of how random experimentation leads to useful byproducts.

A Word About Cognitive Dissonance & Political Leanings

When I speak to others through this line of thought, people usually fall in to two camps.

They either use it as more evidence that business and private companies are evil and simply extract money from consumers.  They argue that we don’t need private interests involved when the government can do everything.

Or they fall in to the camp of people who try to bring up private companies who have produced a lot of valuable technology and are therefore the only solution society needs.  They claim that Private Companies can solve all of the problems faced by society and that the government should step aside.

Yes, there are entrepreneurs out there who are truly innovative and are creating valuable technologies (Jeff Bezos springs to mind), but if you think about it, these types of entrepreneurs have billions of dollars at their disposal to start interesting side projects (e.g. Blue Origin, which is Jeff Bezos’ space programme), while also running a viable business (Amazon).  These entrepreneurs are in the minority.  Most entrepreneurs are in the game of running businesses and “Value Creation”.  And also, keep in mind that Jeff Bezos himself says that Amazon is such a success as all the “heavy lifting” had already been put in place such as the infrastructure for the Internet, roads, railways, delivery processes and worldwide travel, a lot of which is a result of government investment.

The point is that this observation is not a case for or against capitalism / socialism / private companies / government organisations.  It is just that; an observation.

Another observation is that it is the entrepreneurs who take the technology which has been created, make products and services for the market, distribute it and encourage widespread adoption.  This is what Apple did with the iPhone – the technology already existed for the first iPhone, but Apple put it all together in a marketable way.  As a result they created new value and therefore new wealth for society.

And yet another observation is that private companies and government organisations go hand in hand.  Without the private market, technology would just sit unused in government organisations and society as a whole would not benefit from technological advancement.

The argument that private companies can solve all the problems and create all the technologies needed to solve the worlds problems is the same as saying that governments can do it all by themselves.  They are the same in so far as that these are both “theories”.  What I have written about above is an observable fact which has been going on for centuries.

The Domain of the Entrepreneur

Peter Drucker once said that if the technology is not robust, well-tested and proven to work, then it is not ready for the market.  It is out of the domain of entrepreneurs who are concerned with making a marketable product.

Thinking of things in these terms is helpful.

Startups which are trying to create AI in the hopes of replacing physicians will likely fail as the technology behind AI is nowhere near marketable at present.  They have finite resources, unlike government organisations, so they will run out of cash before getting to those important discoveries.

So as an entrepreneur your thinking has to go along the lines of “what problem can I solve with technology that is accessible to me, which will also solve the problem in a better way than how it is solved now?”.

This is a very tricky question to answer as most businesses and entrepreneurs are on the lookout for them most of the time.  This is the reason that if you encounter an obvious problem that a lot of people will give you money for, it is likely a bad business idea.

Peter Thiel once said that the best startup ideas look like bad ideas, but actually they are really good ideas.  The reason is that if a business idea is obviously great, then a lot of entrepreneurs and businesses with a ton of capital backing them will have already created solutions or will be in the process of creating solutions that you, as a lone entrepreneur can’t compete against.

This leaves entrepreneurs with smaller, non-obvious problems to solve.  If it is non-obvious then the larger companies won’t be aware of the business opportunity.  If it is small, then large companies won’t even go after the business as the profits they would make would be too small to make business sense.  However, if you are a lone entrepreneur, then a small win (which could be up to a few million a year in profits), is likely more than enough encouragement needed to pursuit the idea.

First & Second Order Discovery

Paul Graham wrote an essay about having good startup ideas.  It can be summarised in a sentence: “Build cool stuff.”  He goes on to say that building cool stuff, will likely mean that you build new stuff.  If you do build cool and new stuff which solves a problem in your life then it is likely many others also have the same problems for which they will give you money for.

When I started my startup, this is exactly what I did.  I built something cool to solve a problem I experienced as a doctor.  I soon found out that no one would give me money for it.  The problem wasn’t serious enough for most organisations, although they did certainly think I was “cool” for building my own app which my patients now use.

However, what no one had told me when I started my startup is that this is actually the best way to discover something people will give you money for.  This is also the way to discover the elusive “bad idea which is actually a good idea”.

The fact is that coming up with an “idea which seems bad, but is actually good” is a form of second order discovery.  You start something which seems cool, but is likely a really bad business idea.  However, merely the act of starting the journey will get you to a place where no one else has ever been before – almost like an adventurer discovering a new land.  When you get to that place where you’ve built something cool, it is incredibly likely that you will discover problems and then come up with solutions which not only has no one thought about, but certainly that no entrepreneur/business has even addressed.  They simply don’t even know about it!

Let’s take the example of AirBnB.  The founders of the company needed to pay rent, so they put up their living room for rent online.  They figured that people would pay to stay in their living room when there was a convention on in their city and that they would provide their guests with an air-bed to sleep on and serve them breakfast in the morning (thus the name Air Bed & Breakfast).  They couldn’t believe it when it actually worked – so they decided to try to make it into a business.

Many years later, they discovered that they could actually disrupt the hotel market.  There was this whole new market of unused space that people had been looking over for years.  They didn’t have a clue at the beginning that they’d end up with a business worth $30 billion (and counting).

Is anyone in doubt that if Hilton Hotels knew about this untapped market that they wouldn’t have poured all their resources into this opportunity?  The fact is that as it seemed like a bad idea with a small market at first, they didn’t even attempt to address the problem.  But the fact that they wouldn’t address the initial problem meant that they never got to the position to discover this new market.

The myth is that there are geniuses out there who can predict the future and as a result they become wildly successful.  The fact however is that entrepreneurs discover things out of curiosity and luck.  These discoveries then lead to new discoveries and new markets which then puts them in a position to win.

Baby Boomers Vs Millennials!! (They’re both wrong….)

I have seen this conversation played out many times.  Both in the press and in real life.

The Baby Boomer generation often accuse the younger generations of being lazy, flippant with their money and devoid of the grit that is needed to succeed in life.

The Baby Boomers often argue that leading a happy, financially stable life is not all that hard.  Just work at a job, work your way up the corporate ladder, put money aside for a rainy day, invest in a house and you’ll be set for life.

The Millenials on the other hand often talk about how things have changed compared to a few decades ago.  Jobs are harder to come by, you require a degree for most things nowadays, people also accrue a lot more debt due to going to University, the cost of living has gone up as well as house prices etc.

The public discourse is interesting.  The Baby Boomers are right to an extent.  There are millenials who are fine (like myself).  I worked a lot harder than most people of my age and I already feel financially stable.  I also made sure that I did a degree which would definitely lead to a stable job (medicine).  Others who I grew up with are in a much worse state and this could be partially explained by their laziness and extravagant expenditures even when being dirt poor.

However, I disagree with Baby Boomers on a lot of things.  Advice such as “work hard, save money, don’t spend money on silly things” is obvious advice.  Young people are aware of these sentiments and it doesn’t explain how a whole generation is financially so well off and another generation is doing so badly.

The Baby Boomers got used to a different world where wages increased year on year for doing the same work.  They got used to a world where with a small amount of effort they could buy a house due to their increasing wages.  But what Baby Boomers don’t seem to realise is that their increasing wages had very little to do with anything that they were actually doing.  The reason that they became wealthy was actually due to technological advancements and massive economic growth during their working years.

As older generations don’t realise that this was actually the reason they became financially stable, they keep giving the same advice; “Do well at school, get a degree, get a job, work your way up the corporate ladder, save money, invest in a house…”.

The millennials that follow the classic advice are obviously not getting the same results as the older generations.  But what no one ever talks about is where wealth comes from and how it is created.

This is what is missing from the argument that is always played out.  Millennials (such as myself) should not be demanding house prices to be reduced, or more handouts from the government – because this is unrealistic and economically non-viable.  Millennials should be concentrating on creating new wealth by creating value.  This is the answer that they’ve been looking for.

Your Perception Of Money Is Why You’re Poor

 A Quick Anecdote About Getting Into Shape

When I was a Junior Doctor, I would often say bye to the receptionists and admin team on my way out for the day.  They’re usually sat near the exit of any given ward or clinic, so it would be awkward to not at least nod and smile.  This was my usual method of exit.  However, sometimes even if you’re in a rush and have had a grueling shift there’s an unspoken expectation that you should spend some time to speak with the rest of the team.

On one of these occasions the conversation turned to my eating habits.  Now I’m a bit of a fitness guy, so I can look at a piece of food and guesstimate it’s caloric content and macronutrient composition.  Anyone serious about reaching fitness goals are aware of these basic concepts and are mindful about what they introduce into their system.

When I was explaining that I had a nice chicken stew with beans waiting for me at home that evening, the receptionist said:

“If I were as slim as you, I wouldn’t watch what I eat…”.

I didn’t think much of it at the time, but I think this single sentence perfectly sums up why so many people are clinically obese, unhappy and poor.

The simple truth is that I am in shape and fit because of my diet and lifestyle.  The very fact that the person I was speaking to would not watch what she would eat if she herself was slim is the very reason she will never be slim.  The outcome is a result of the process.  The process will change the way you perceive food and your relationship with food.  Food for me is a source of energy to allow me to function at a higher level.  Yes it is also a pleasurable experience, but the overall benefits I can feel by consuming wholesome foods far outweighs any short-lived dopamine burst from a diet entirely composed of McDonald’s.

Being healthy doesn’t mean you can’t still derive pleasure from food…

Your Perception of Money

Here’s the thing.  The attitude towards diet illustrated above is the same reason why people don’t get rich.  How many times have you heard people say the following:

“If I were rich I would stop working!”

The very fact that you would stop working is the reason you will not get rich.  Your relationship with money is a destructive, warped one.  In the same way that most people eat for pleasure, most people only use money for consumerism i.e. buying creature comforts.

If one can accept the fact that perhaps people in rural India perceive money in a radically different way to how the majority of the west perceive money, then it is reasonable that the very rich perceive money in a very different way to the majority of the west.

People in rural India see money as a means of survival.  To put food in their stomachs and provide the essentials for their family.

The majority of people in the west see money as a means of consuming ever more products and services.  Most of what is consumed by the majority in the west are non-essential.

How Rich People Perceive Money

I’ve had this conversation many times with different people.  Most people get defensive when I point out that they are not as frugal as they claim to be.  People may believe that the clothes they buy are “essentials”, but when asked how many shirts they have which they do not wear or have not ever worn, they go quiet.  They go quieter still when I ask where they buy their shirts.  “You bought your shirt from Zara?  Why didn’t you get your shirt from the supermarket for a much cheaper price?  Why do you buy branded cereal when the supermarket own brands are basically the same and are much cheaper?”.

If you can answer these questions objectively then you’re getting much closer to how to perceive money.

Most people at this point have a knee jerk reaction.  “Shirts from the supermarket aren’t as durable…..I can taste the difference between supermarket branded cereal and the branded cereal”.  Really?  Have you carried out double-blind randomised trials to prove this point?

Most of the time the difference is zero.  In fact, I know some factory owners who manufacture clothes in Bangladesh (the second largest textiles producer in the world) and most clothes – even a lot of the high-end designer products come from the same place with a different brand stamped on at the end.

No, the reason you purchase the higher end stuff and not the cheapest option is your perceived value of what you are buying.

And this is the closest to the truth.

Money is the exchange of perceived “value”.

And when you realise that “value” is not the cost of the bare components of a product – but the branding, the feel, the service you receive, the customer support etc it becomes apparent that you can actually create value.

What Does This All Mean??!

The point I am trying to make is that money is used by rich people as a means to an end.  It is not the end goal in and of itself.  America as a nation gets this much more than anywhere else in the world.

Money is used by rich people to exchange value.

They hire people with money (aka value tokens) to create their products and services.

These workers create even more value, which society then consumes.

More value for society results in more income for the business which results in more job and more money (value tokens) for everyone in society to create more wealth and value.

Value tokens are used by most people in society to just consume, but this is the same as eating pizza to get slim.

Henry Ford

Henry Ford once famously raised the wages for his workers to $5.  This at the time was double the minimum wage.  The other factory owners were outraged.  “If Henry Ford raises wages, then all our workers will leave!  We’ll also have to raise our wages too!” they said in outrage.

Later on Ford was taken to court for wanting to reduce the dividends provided by his company to certain shareholders and grow his company further.  He understood that giving higher wages would encourage his workers to give their best and that paying less dividends would allow him to create even more value.

There is a transcript from court which illustrates precisely how successful business people view money (Henry Ford in this instance) and how the majority of people perceive money (Attorney Stevenson).  If more people could view money in the way Henry Ford did, then the world would be a much better place.

Attorney Stevenson (AS): “Now, I will ask you again, do you still think that those profits were “awful profits” (Stevenson was quoting Ford from a Detroit News interview)?”

Henry Ford (HF): “Well, I guess I do, yes.”

AS: “And for that reason you were not satisfied to continue to make such awful profits?”

HF: (Ford looking apologetic) “We don’t seem to be able to keep the profits down.”

AS: “…Are you trying to keep them down?  What is the Ford Motor Company organised for except profits, will you tell me, Mr Ford?”

HF: “Organised to do as much good as we can, everywhere, for everybody concerned.”

AS: Stevenson again asked what the “purpose” of Ford’s company was.

HF “Give employment, and send out the car where the people can use it… and incidentally to make money…Business is a service, not a bonanza.”

AS: “Incidentally make money?”

HF: “Yes, sir.”

AS: (In a sarcastic tone) “But your controlling feature…is to employ a great army of men at high wages, to reduce the selling price of your car, so that a lot of people can buy it at a cheap price, and give everyone a car that wants one?”

HF: (Ford destroys the argument by agreeing with it) “If you give all that, the money will fall into your hands; you can’t get out of it.”

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:

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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.