That’s a quote from Josh Kaufman’s How to Fight a Hydra. Here’s another:
Fear of the unknown will always be with you, no matter what you do. That’s comforting in a way: if there’s nothing you can do to change it, there’s no reason to let it stop you.
From Company of One: Why Staying Small Is the Next Big Thing for Business by Paul Jarvis:
I like reading things that are not about medicine and seeing what lessons cross domains and apply. The premise of Jarvis’ book is that growth for growth’s sake is a terrible business model for many businesses and especially the many people that run them. It’s okay to be big, but any decision to grow the enterprise should be an active choice considering all factors and not just the default MO taken from the recent start-up culture of silicon valley.
My wife left her employed university position last year to start a solo private practice, and it’s been wonderful. It’s not hard to see how there are so many downsides to being part of large company or expanding your own business too much. On the former, no control. On the latter, so much time managing the machine that it’s easy to completely lose track of why you started the practice and what you liked about it.
But here are four passages that also resonated with me as a physician and educator:
Miles Kington, a British journalist, reportedly said that “knowledge is knowing that a tomato is a fruit. Wisdom is not putting it in a fruit salad.” We should never assume that having an abundance of knowledge is the same as having an abundance of wisdom.
This is the problem with equating performance on a knowledge assessment like a high-stakes multiple-choice examination with real-life competence. Knowledge is important, but it doesn’t mean you can perform in your field.
More isn’t better—better is better. There are advantages to putting in the time and effort to master a skill, but there’s also a great need for balance.
“More isn’t better” is a real truism for so many things in our world. We should question whenever something or someone simply wants more of us: more hours, more years of training, more free labor, more notches on the CV belt. It’s not necessarily that the “more” is inherently bad—it almost never is—but that doesn’t mean it’s worth it.
Sukhvinder Obhi, a neuroscientist at McMaster University, coined the term “power paradox” to describe what happens when we gain power through leadership: we subsequently lose some of the capabilities we needed to gain it in the first place—such as empathy, self-awareness, transparency, and gratitude.
The power paradox explains much of the bullying we see within strict hierarchies: how excrement rolls downhill from the top of a poorly-run organization all the way to the youngest least experienced students who are just doing their impressionable best to insulate themselves from the worst of indoctrination as they grow.
[Cal Newport, author of So Good They Can’t Ignore You] believes that we need to be craftspeople, focused on getting better and better at how we use our skills, in order to be valuable to our company and its customers. The craftsperson mind-set keeps you focused on what you can offer the world; the passion mind-set focuses instead on what the world can offer you.
There are some people who in life (or medical school), are confident they know exactly what they want. They are passionate about dermatology and orthopedic surgery. That’s great.
But I don’t think there’s anything wrong with the rest of the world, those who simply don’t know or seem to be missing that “passion.” I agree with Newport that passion is something you can grow through competence and the craftsmen mentality. There are no perfect jobs or fields. There are good and bad aspects to everything, and suggesting otherwise drives so much anxiety in the specialty and residency-selection process.
Success has more to do with you, your goals, and your perspective than it does with exactly what box you place yourself in.
From How to Think About Money by Jonathan Clements:
First and foremost, money buys time and autonomy. Secondarily, it buys experiences. Last, and least, it buys stuff, and more often than not, the stuff we buy makes us miserable.
Most people live their lives with these in the opposite order, but Clements is absolutely right.
You don’t have to be a FIRE-fanatic to realize that setting up your professional life, spending, and saving to optimize for number one is the winning strategy.
Simple Sabotage: A Modern Field Manual for Detecting and Rooting Out Everyday Behaviors That Undermine Your Workplace is a book inspired by a real World War II CIA field manual called “Simple Sabotage” that was written to help “guide ordinary citizens, who may not have agreed with their country’s wartime policies towards the US, to destabilize their governments by taking disruptive action.” You can read the declassified original document at that link.
It’s short and fascinating and much of it is timeless. Operationally, it functions as a “how-not-to” for creating an efficient organization. The CIA’s top 3 takeaways:
1. Managers and Supervisors: To lower morale and production, be pleasant to inefficient workers; give them undeserved promotions. Discriminate against efficient workers; complain unjustly about their work.
2. Employees: Work slowly. Think of ways to increase the number of movements needed to do your job: use a light hammer instead of a heavy one; try to make a small wrench do instead of a big one.
3. Organizations and Conferences: When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committees as large and bureaucratic as possible. Hold conferences when there is more critical work to be done.
These points were once felt to be a great way to sabotage Nazi Germany, but they seem to have been voluntarily taken up by most modern American businesses.
A good example from the book is the “obedient saboteur,” someone who—by doing exactly what he’s told to do—is actually making things worse:
This problem can be particularly acute in organizations with a culture of “continuous improvement.” Continuous improvement is a business philosophy created by W. Edwards Deming in the mid-twentieth century. This philosophy thinks of processes as systems and holds that if each component of the system constantly tries to both increase quality and reduce costs, efficiency and success will follow. But taken to an extreme, even continuous improvement can lead to sabotage.
One company we know had a call center manager driving his team to move from an average pickup speed of 1.4 rings to 1.2 rings. The division head asked, “How often do callers abandon us after only 1.4 rings?” “Almost never,” he was told. “Virtually no callers who actually intended to call us hang up before the third ring.” Yet the call center manager persisted in trying to ensure that all calls were answered more quickly each year. Why? Because getting the phones answered quickly was his job—by definition, quicker was better. He never thought to question whether he had crossed the threshold where process had overridden outcome. He had become one of the Obedient Saboteurs. If you asked him why he was trying to lower pickup times, he would tell you that faster pickup means improved customer experience. That’s true—but the threshold is three rings. Once you get below three rings, faster pickup times don’t continue to improve the customer’s experience anymore.
The problem we see, time after time, is that nobody bothers to go back and tell the call center managers of the world to go continuously improve something else.
To keep this kind of sabotage out of your group, step back and conduct a formal review of any continuous improvement programs you have in place. If they aren’t relevant anymore, pull the plug.
Also see: measure what matters.
To fight back, ask yourself:
What is the stupidest rule or process we have around here?
What are the three biggest obstacles you face in doing your job?
If you could rewrite or change one process or procedure, what would it be and why?
A lot of quality improvement isn’t real:
It’s adding clutter. It’s replacing content with process.
We should be just as ruthless when evaluating quality measures and metrics as we are with the fail points that inspire them.
From Machine, Platform, Crowd: Harnessing Our Digital Future by Andrew McAfee and Erik Brynjolfsson:
Research in many different fields points to the same conclusion: it’s exactly because incumbents are so proficient, knowledgeable, and caught up in the status quo that they are unable to see what’s coming, and the unrealized potential and likely evolution of the new technology.
This phenomenon has been described as the “curse of knowledge” and “status quo bias,” and it can affect even successful and well-managed companies.
There are a lot of bad actors in healthcare that I would love to see fall prey to the curse of knowledge.
From Doughnut Economics: Seven Ways to Think Like a 21st-Century Economist by Kate Raworth (emphasis mine):
Despite such misgivings from the twentieth century’s two most influential economists, the dominance of the economist’s perspective on the world has only spread, even into the language of public life. In hospitals and clinics worldwide, patients and doctors have been recast as customers and service-providers.
There may be no perfect frame waiting to be found, but, argues the cognitive linguist George Lakoff, it is absolutely essential to have a compelling alternative frame if the old one is ever to be debunked. Simply rebutting the dominant frame will, ironically, only serve to reinforce it. And without an alternative to offer, there is little chance of entering, let alone winning, the battle of ideas.
But when political economy was split up into political philosophy and economic science in the late nineteenth century, it opened up what the philosopher Michael Sandel has called a ‘moral vacancy’ at the heart of public policymaking. Today economists and politicians debate with confident ease in the name of economic efficiency, productivity and growth—as if those values were self-explanatory—while hesitating to speak of justice, fairness and rights. Talking about values and goals is a lost art waiting to be revived.
I love that.
And the example of healthcare I think is exactly right. Everything is a business—that’s unavoidable. It isn’t even a bad thing. Lose money and you won’t be in business very long. But not all businesses need to be organized with the primary purpose of optimizing productivity and growth.
Good patient care is inefficient. Talking to people—understanding their perspective and helping them become active participants in their health—takes time. A patient visit was never meant to be an assembly-line 15-minute med check.
It’s not that we should applaud or celebrate inefficiency. There is plenty of waste to trim in any enterprise. It’s that these ideas—efficiency, productivity, and growth—should be tools to achieve meaningful ends, not the primary endpoint. Measure what matters.
And if some of that extra “value” makes it to the actual workers? Much of our economy is predicated on individuals misallocating their income away from savings and away from optimizing their time:
As economist Tim Jackson deftly put it, we are ‘persuaded to spend money we don’t have on things we don’t need to make impressions that won’t last on people we don’t care about’.
From Cal Newport’s Digital Minimalism: Choosing a Focused Life in a Noisy World:
The techno-philosopher Jaron Lanier convincingly argues that the primacy of anger and outrage online is, in some sense, an unavoidable feature of the medium: In an open marketplace for attention, darker emotions attract more eyeballs than positive and constructive thoughts. For heavy internet users, repeated interaction with this darkness can become a source of draining negativity—a steep price that many don’t even realize they’re paying to support their compulsive connectivity.
Encountering this distressing collection of concerns—from the exhausting and addictive overuse of these tools, to their ability to reduce autonomy, decrease happiness, stoke darker instincts, and distract from more valuable activities—opened my eyes to the fraught relationship so many now maintain with the technologies that dominate our culture. It provided me, in other words, a much better understanding of what Andrew Sullivan meant when he lamented: “I used to be a human being.”
Doomscrolling is so insidiously toxic.
I am not a heavy social media user. I mainly use Twitter to make sure I interact with readers who use that medium and to share my newest articles. Since 2009, my main use of Twitter has been to publish other people’s tiny stories in Nanoism, an admittedly bizarre hobby and a largely one-way broadcast (@nanoism). I actively dislike Facebook.
And yet.
Sometimes I find myself scrolling and scrolling, clicking on a shared link to another depressing rantorial and then reading the awful comments from strangers on the internet who didn’t read the actual article acting out their respective caricatures. It all makes me wonder if humans are actually the creatures of morality and reason as argued by some philosophers. For most internet platforms, anger and outrage are features. Yelling at strangers on the internet is gold for companies that serve you targeted ads and profit from your attention. Everything is tailored for engagement.
One app I desperately needed when I was a student is Freedom, a service that allows you to block certain activities either on-demand or on a schedule. It would have saved me from a lot of my old internet demons. I should probably even turn it on more now, but I’m usually in a better place these days. Having young kids to soak up my time and attention has helped me hone my focus.
But Newport takes it a step further, and I think he’s right. It’s not enough to try to limit the damage of new technology or platforms on your life:
I’ve become convinced that what you need instead is a full-fledged philosophy of technology use, rooted in your deep values, that provides clear answers to the questions of what tools you should use and how you should use them and, equally important, enables you to confidently ignore everything else.
Many finance gurus talk about the need for all of us to have “Investor Policy Statements” or a “Written Financial Plan.” The reason being that if you don’t articulate a specific position, you may react inappropriately to the vagaries of life in a way that is counter to your goals. The plan keeps you honest and helps you deal with anxiety.
It makes sense to plot out “use criteria” so that you know if you should be incorporating the newest social media service that comes along and not just reactively picking something up because it’s popular.
Likewise, it makes even more sense to look critically at your use and see where the utility lies. You may not want to delete your Facebook profile or remove Instagram from your phone. Fine, right? But what—specifically—about using those services makes you happy, and what makes you angry, hurt, or jealous? And, knowing that, how can you structure some rules for engagement that can help you get what you want from the platform instead of letting it became just another automatic behavior?
From the highly readable Nobody Wants to Read Your Sh*t by Steven Pressfield:
You begin to understand that writing/reading is, above all, a transaction. The reader donates his time and attention, which are supremely valuable commodities. In return, you the writer must give him something worthy of his gift to you. When you understand that nobody wants to read your shit, you develop empathy.
Dear reader, I feel for you. Thanks as always.
Regarding persuasive nonfiction:
Here’s the wrong way:
1) Introduce the thesis (first three chapters).
2) Cite examples supporting the thesis (next hundred chapters).
3) Recap and sum up what you’ve presented so far (last five chapters).In other words, “Tell ‘em what you’re gonna tell ‘em, tell ‘em, then tell ‘em what you’ve just told ‘em.”
This is salient advice, and it perfectly explains why every time I read self-help or one of these pop-psych “here’s how things really work” books it feels like the whole thing should have been a blog post or two.
I just finished John Carreyrou’s Bad Blood: Secrets and Lies in a Silicon Valley Startup, about the fall of Elizabeth Holmes and Theranos, the Silicon Valley Unicorn that pretended to be a pioneer in laboratory testing but was really just a purveyor of bloated promises and outright lies.
A sociopath is often described as someone with little or no conscience. I’ll leave it to the psychologists to decide whether Holmes fits the clinical profile, but there’s no question that her moral compass was badly askew. I’m fairly certain she didn’t initially set out to defraud investors and put patients in harm’s way when she dropped out of Stanford fifteen years ago. By all accounts, she had a vision that she genuinely believed in and threw herself into realizing. But in her all-consuming quest to be the second coming of Steve Jobs amid the gold rush of the “unicorn” boom, there came a point when she stopped listening to sound advice and began to cut corners. Her ambition was voracious and it brooked no interference.
A 19-year-old with a couple of semesters of chemistry under her belt suddenly knows enough science and engineering to demolish the scientific state of the art and maybe even the laws of physics when it comes to fluid dynamics. Even the products themselves kept pivoting as her original ideas were clearly impossible with the current state of technology and the people she brought in to do the actual work rotated through.
It’s bonkers, and it’s so telling that almost everyone investing was a tech billionaire or silicon valley VC with no understanding of science. A cult of personality has no business in healthcare without data. This was Holmes describing the Theranos lab process:
A chemistry is performed so that a chemical reaction occurs and generates a signal from the chemical interaction with the sample, which is translated into a result, which is then reviewed by certified laboratory personnel.
If you heard this in a pitch meeting, would you think future of medicine or middle school book report?
I remember the news when Theranos imploded and I think a lot of people fully embraced the schadenfreude. But reading the detailed story was just so depressing. You shouldn’t be able to run a science company while hiding all the research and data. You know, all the sciency stuff. That’s literally not how science works.
How many thousands upon thousands of hours of smart folks’ time was wasted trying to duct tape vaporware when they could have been making a substantive contribution to their fields. How much money was flushed for someone’s ambition?
Continuing my tradition of posting my annual book diet, this year wasn’t nearly as good of a reading year as 2018. 2019 was (extremely?) busy with the birth of our baby daughter, the continued raising of our four-year-old son, my wife starting a solo private practice (that’s another post), and my first full year as an attending (and winning teacher of the year to boot!).
I think 2020 is going to be a good year. I already know what my first book is going to be.