On July 4th, as the country turned 250, I read something in a newsletter called Category Pirates that really resonated with me about what makes America unique.
Since 2007, Gallup has asked people in more than 150 countries a simple question: if you could move anywhere on Earth, where would you go? Every single year, the same country wins, and it isn’t close. About 140 million people choose the United States. The runner-up, Canada, draws about half that.
It would be easy to assume this is about resources, or wealth, or opportunity in the abstract. It isn’t. In nearly every other country on Earth, you belong by blood. You’re born into a family, a class, a caste, and that is largely where you stay. In America, you belong by what you build. Immigrants and their children founded nearly 60% of America’s billion-dollar startups. Almost 80% of U.S. unicorns have an immigrant founder or key leader. Most of these people did not arrive with advantages. Most arrived with none. They came because this is one of the only places that asks two questions almost nowhere else asks: do you believe this can work for you, and what are you going to build?
Build versus blood. That distinction is worth sitting with if you run a practice, because the same newsletter told a second story that shows exactly how building creates value that inheritance never could.
In 1865, a British economist named William Stanley Jevons noticed something that should not have been possible. Steam engines were getting more efficient, using less coal to do the same work. Every economist of the era predicted the obvious result: coal consumption would drop.
It didn’t. It exploded.
More efficient engines made coal-powered production cheaper. Cheaper production meant more businesses could afford steam power. More businesses adopted it. New value got created that hadn’t existed before. Total coal consumption went up, not down.
This became known as Jevons Paradox: greater efficiency doesn’t reduce demand for a resource. It increases it. And it only happens because someone builds something new on top of the efficiency. Nobody inherits that outcome. It gets built.
The Reality: Skill Was Never the Whole Story
Most practice owners assume that getting clinically better, faster, and more efficient is itself the growth strategy. Improve the medicine, and the patients, referrals, and revenue follow.
It’s a reasonable assumption. It’s also incomplete.
Coal never grew an industry by itself. Steam engines never grew an industry by themselves. What grew industries in the 1800s was what people built around that efficiency: new factories, new products, new markets that cheaper power made possible.
The same newsletter told another story that makes this concrete: American farming. Between 1790 and today, Americans didn’t just get better at growing crops. We built the railroad, which let crops travel farther. We invented electricity, which let crops be preserved through refrigeration. Then came the automobile, which let consumers bring crops home. Followed by the computer, which let people plan what to buy. Add the internet, which gave them recipes. And now we have the smartphone, so they could share pictures of the meal.
The crop was never the whole story. It needed a system built around it before it turned into real, compounding value.
Clinical excellence works the same way in your practice. It’s the coal. It’s the crop. It’s necessary, and it is rarely what patients are actually evaluating when they decide whether to trust you, refer you, or come back.
The Shift: Build the System Around the Skill
If clinical excellence alone grew practices, every technically gifted physician would have a waiting list. Many don’t. What separates the practices that grow from the ones that plateau is not more skill. It’s the system built around the skill: how a patient is greeted, what happens between the consult and the procedure, how the team communicates, what happens when something goes wrong, whether everyone on staff is telling the same story about why this practice is worth choosing.
This is what we mean when we say patient experience is a system, not a personality trait. It’s not about hiring nicer people. It’s about building the railroad, the refrigeration, the delivery infrastructure around the clinical work you’re already doing well.
This also answers a question I hear constantly right now: will AI make the human side of practice less necessary?
Category Pirates made an argument worth borrowing. In 1995, world GDP was roughly $31 trillion. Thirty years after the internet, it’s approximately $110 trillion. The internet didn’t shrink demand for human judgment, human service, or human connection. It multiplied the number of places those things mattered.
AI will do the same thing to your practice. It will make the clinical and operational work more efficient. That efficiency will not reduce what patients need from the humans in your building. It will raise the bar on it, and it will reward the practices that already built the system to capture the value that efficiency unlocks.
The practices that treat AI and automation the way the economists of 1865 treated the steam engine, as a threat to demand, will have the story backwards. The practices that build the infrastructure around their clinical excellence will be the ones who benefit most from it.
Build, Not Inherit
Two hundred and fifty years in, the country’s whole story has been proving that what you build outlasts what you’re born into. That is not just a story about immigration or GDP. It is the story available to every physician who didn’t inherit a referral base, a legacy practice, or a recognizable name, and built one anyway.
The same freedom that draws millions of people to bet on building something in America is available inside your practice right now. AI and better tools are not going to take that away. If anything, they are about to make it possible to build faster than any generation of physicians before you.
The next 25 years of medicine will not be won by the practices with the most inherited advantages. They will be won by the ones willing to build. That should be the most encouraging sentence you read all week.
Happy Birthday, America! And may the next 250 years be as incredible as the last.
If you’re ready to see what that building looks like in your own practice, a PX FitCheck is a good place to start: https://pxmovement.com
Another podcast? Yes! And this one is unique because 3 surgeons in the same market area have decided to collaborate rather than compete when it comes to sharing information that can help doctors improve their practices and their lives. How cool is that! Sonny Goel, Andy Holzman and Jon Solomon get together and discuss topics important to doctors and patients in their listening audience. I was honored to be their first guest and enjoy their candid conversation. Join the conversation on LinkedIn. Let them know what you think and what you want them to talk about!