Alcoholics Anonymous is likely the most well-known program for sobriety. It has nearly two million members worldwide, and it’s the default treatment for alcoholism in US healthcare.
I’m interested in studying AA because of its profound potential for behavior change. Alcoholism is a notoriously intractable condition. Genetics predisposes some people to alcoholism; changes in alcoholics’ brains put potential for relapse on a hair trigger.
That Alcoholics Anonymous can get a subset of patients to never drink again is impressive. That it does so non-pharmacologically – really, with just words and people – makes it well worth studying. Its practices, structure, and approaches to new alcoholics are a master class in persuasion.
The Big Book is Alcoholic Anonymous’s primary text. (long title: Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism). The Big Book is one of the best-selling books of all times (30 million copies sold). It originated the “twelve-step program” now used widely among addictions outside alcohol. During a time when alcoholism was seen primarily as a character defect, the Big Book spread the paradigm of alcoholism as an illness.
In this summary and analysis of The Big Book, learn:
The principles behind Alcoholics Anonymous, and why they work for alcoholics
Why the “belief in a higher power” is not as problematic as you may think
The powerful persuasive techniques AA use to recruit members and get them onboard
Remember how this company Birchbox was everywhere 3 years ago? And how today it’s…not?
Turns out after raising $90 million at a peak valuation of $500 million, and after a few years of struggle, in 2018 Birchbox sold a majority stake to a hedge fund for only $15 million. This means after a journey of 8 years, its investors were totally wiped out. Employees who had exercised stock options came out with nothing.
Admittedly, I wasn’t a target customer, and this might have been obvious to their user base for years. But that this wasn’t bigger news (at least in the sources I read) reflects an ever-present survivorship bias in entrepreneurship. The companies that survive soak up the attention; the failed companies fade away with a whimper. We forget how much hype they built up years ago, and we turn our attention to the next hot thing.
But failed companies are where some of the best lessons can be learned. Warren Buffett says, “it’s good to learn from your mistakes. It’s better to learn from other people’s mistakes.”
Studying failed companies helps you better differentiate strategies that work from ones that don’t. Studying failed businesses helps you look past platitudes like “culture is everything” to understand the fundamentals of why many businesses fail and some succeed. Studying failed startups helps you discount today’s breathless press hype, and better try to predict the future.
I’ve done a deep dive into 59+ failed startups. Each has a meaningful story to learn from.
Most of these were venture funded by big names: Andreessen Horowitz, Sequoia, Kleiner Perkins.
They raised on average 8 figures of funding, some with $100 million+ – these were serious contenders, once strongly believed in by professional investors.
Many of them have postmortems written by a founder, complemented by third-party analysis of why they failed.
I hope they’re as useful to you as they were to me.
The Hacker’s Diet was written by John Walker, founder of software company Autodesk. This is an engineer’s approach to weight loss, described in terms of control systems, feedback loops, measurement noise reduction, and practical problem-solving.
With so many contradictory theories of weight loss out there, The Hacker’s Diet cuts out the bull – it’s about calories in and calories out, period. If you’re fat, you’re fat because your eating control system is broken. To you, cutting back calories is intensely painful, but there’s little stopping you from overeating well beyond your daily maintenance calories.
It’s simple. But simple doesn’t mean easy. The key is to execute.
The systems and strategies described in The Hacker’s Diet are eminently practical, in that “I can’t believe I didn’t think of this before” way. In this Hacker’s Diet summary, learn:
How your internal eating control system is broken, causing you to eat way more than you should
The sane way to track your weight to avoid daily fluctuations of 2-4 pounds
Why the first few days of dieting are the hardest that dieting will ever be
What you have to do to maintain your ideal weight for the rest of your life
Earlier this year, Jeff Bezos (Amazon), Warren Buffett (Berkshire Hathaway), and Jamie Dimon (JP Morgan Chase) announced a joint venture to tackle healthcare costs. Recently, they named famed medical writer and surgeon Atul Gawande to be the venture’s first CEO.
Very few details about what the venture is actually doing have been announced, leading some to speculate. The more obvious low-hanging fruits are cutting out middlemen like pharmacy benefit managers (hence Amazon’s acquisition of PillPack) and getting some returns on scale by self-insuring a million employees across the 3 companies.
But I think a lot of speculators are missing the point. I predict ABC Health’s ultimate vision is to create a nationwide insurer that can service an entire nation’s employers and consumers. Much like how 64% of US households are Amazon Prime members, ABC Health hopes to build a payer system that the majority of US households will subscribe to.
Getting to that point is the challenge. Here I’ll describe what I see as the root problems of US healthcare costs, the central strategy that will get ABC Health to massive scale, and the exciting opportunities available to it.
Why DO we get sick? Why hasn’t natural selection, over millions of years, prevented us from getting cancer, heart disease, and depression?
Our bodies seem at times to be faulty designs, prone to error and calamity. Diseases seem like mere accidents of evolution (like the appendix). Or perhaps natural selection just isn’t powerful enough to get rid of some diseases?
The science of evolutionary medicine says this thinking is totally, utterly wrong. Instead, our bodies have evolved over millions of years as a set of compromises, largely in pursuit of reproductive fitness. Frankly put, whatever gets you to survive and have kids is going to persist in the gene pool, even if it causes you lots of disease and pain in adult life.
Why We Get Sick is one of the most insightful and profound books on disease I’ve ever read (including all of my medical school training). After reading this summary, I don’t think you’ll look at disease – and humans in general – the same way again.
In this Why We Get Sick summary, you’ll learn:
Why humans haven’t evolved to live for 200 years, and why we don’t regrow limbs
The evolutionary purpose of depression
Why females evolved to bear children, and why this has led to the classic male fear of commitment and all sorts of confusing sexual behaviors (it takes a few logical steps, but trust me)
How the fact that we evolved in small tribes in the Stone Age, combined with today’s mass media, may increase depression
Why we’ve evolved to dislike the sound of baby crying
American healthcare is commonly known to be in a deplorable state, costing 18% of GDP while underperforming in quality among developed nations. Changing the situation systemically also seems intractable – Obamacare endured a torturous path of compromises and ended as a sliver of its original ambition. Costs continue to rise without a clear winning strategy.
American Sickness unpacks how US healthcare got to this state. It examines the competing interests of the major blocs in healthcare – hospitals and doctors, pharmaceuticals and devices, and insurers. It’s the most helpful book on US healthcare I’ve read thus far, clarifying how deeply entrenched the interests are and why it’s so difficult to change anything.
American Sickness is written by Dr. Elisabeth Rosenthal, who trained at Harvard Medical School and served as a reporter at the New York Times for 21 years. It’s currently a top 5 Amazon bestseller in healthcare.
In this American Sickness book summary, you’ll learn:
Why healthcare systems have undergone massive consolidation
The incentives pushing hospitals and doctors to give you expensive, unnecessary care
How doctors have regularly protected their own interests at the cost of patients
How pharmaceutical companies manipulate patent and prescribing law to fight off cheaper generics
What you can do today to lower personal health costs
Data privacy is the topic du jour, given Facebook’s Cambridge Analytica mishap and the ubiquitous tracking that follows you everywhere on the web.
You might want to know that your medical data is no safer. Your healthcare providers – pharmacy, hospital, health insurer, lab test provider, genome sequencers – are continuously selling your medical data to data brokers. Data brokers compile this information into a patient record, which is then resold with records of hundreds of millions of other patients for marketing and industry analysis purposes.
Our Bodies, Our Data: How Companies Make Billions Selling Our Medical Records, by Adam Tanner, is a useful survey of the medical data industry and its current worrisome capabilities. You’ll learn how the industry progressively sold more and more data, how patient records are compiled, and why there’s a market for this data.
In some sense, it’s already too late to opt out or take back your data. Data brokers say your records can’t be traced back to you, so even if you wanted to opt out, it claims to have no way to tell which data to delete. But at minimum, you should be aware of the extent to which your data is shared and be sensitive to future opportunities to opt out, should you so choose.
Much is said about the deplorable state of US healthcare: it costs 18% of GDP, shows low quality relative to comparable countries, and any major changes are high-friction and glacial in speed.
US healthcare is also incredibly complex, characterized by fragmentation; opposing incentives that are deeply entrenched; an opaque, inefficient market; and philosophical divides between people who believe in market justice vs social justice.
Essentials of the US Healthcare System, by Shi and Singh, is a useful high-level primer to the structure of US healthcare and the history behind its current state. This summary contains my takeaway notes from Essentials and open questions about US healthcare I’m still trying to answer.
This is part of a series on US healthcare as I try to find a problem tractable for a startup to work on. If you know of anyone working on compelling problems in healthcare or behavior change, please put them in touch!