The Hollow Win: What the Climb Costs You by Forty-Seven
It’s 1996. I’m seventeen, lying face down on a wrestling mat in a sports hall that smells like old leather and sweat. My coach presses his knee into my back.
“You break him, or he breaks you. There is no third option.”
I heard some version of that line four times a week starting at age twelve. By the time I stopped competing at twenty-five, it was second nature. Read the room. Find the leverage. Finish the point. Everything became a point: school, exams, even client meetings in my thirties.
Thirty years later, I’m sitting on a terrace in Malta with eight other men. Six are surgeons, and three run hospital departments. Each of us learned some version of what my coach taught me. In different places, we were all trained to find leverage and finish the point.
It’s Friday night. One of the men at the end of the table has a brain tumor that has come back. This trip is on his list. The surgeon with the longest CV refills his glass before his own.
There’s no leverage here. No point to finish. None of our training prepared us for tonight, and this is the only thing that matters.
The Experiment on the Terrace
For two days, I’ve watched nine versions of the same experiment.
Each of us was picked for the same trait, in our own way. You don’t run a department, build a practice, make partner, or close a Series B without it. Psychiatrist Paul Conti describes three drives that compete in every adult: Generative, the urge to create, contribute, and build something lasting; Aggressive, the energy to compete, control, assert, and accumulate; and Pleasure, the pull toward satisfaction and enjoyment [1].
In a healthy system, Generative is in charge. Aggressive and Pleasure are still there, but they support the one in the chair.
The corner office, senior partner role, chief surgeon position, and founder seat are all twenty-year filters for the opposite setup. They select for Aggressive being in charge. By forty-seven, your inner system has run this way for so long you don’t notice it. You think it’s just who you are.
That’s the experiment I’m watching this weekend: nine men trained in Aggressive, but none of them using it.
The Three Drives
Every adult has all three drives running at all times. The real question is which one is in charge.
The Generative drive builds, teaches, creates, and contributes. It writes the chapter that took three years to learn. It operates on the patient who can’t pay the full fee because the case is interesting and the family is scared. It stays the extra hour with the junior who’s going to leave the firm anyway. It grows with age because it doesn’t depend on winning.
The Aggressive drive engages with the world; not violence, but the urge to compete, control, defend, and take ground. Healthy people use it as a tool. It builds practices, closes deals, and runs operating rooms under pressure. When it’s in charge, every flat surface looks like a hill.
The Pleasure drive pulls us toward sensation, satisfaction, and enjoyment. The wine, the holiday, the meal, the achievement as a trophy. It’s useful when it serves the others, but when it’s in charge, it ends up consuming what it was supposed to enjoy.
Conti’s model is hierarchical. For mental health, Generative should be in charge, Aggressive provides the drive, and Pleasure adds flavor. The order matters [1].
Why Aggressive Wins by Forty-Five
Two forces come together to put Aggressive in charge by midlife. The first is selection.
The path to seniority in any high-stakes field is a twenty-year competition: medical school, residency, fellowship, attending, division chief; associate, manager, principal, partner; analyst, founder, exit, next company. At each stage, those with the most Aggressive drive move forward. Usually not the most generative or curious, but the most willing to compete, defend ground, and take the next hill.
The second force is neurobiological. Robert Sapolsky spent decades with a baboon troop in Kenya’s Masai Mara. In stable hierarchies, dominant animals carry the lowest cortisol and the lowest atherosclerosis incidence. The system rewards the position. In unstable hierarchies, where the dominants must constantly defend their standing, the pathology load inverts. The dominants now carry the most severe cardiovascular, immunological, and adrenocortical damage in the troop [2]. They keep the rank. The body pays for it.
Modern corporate, surgical, and professional hierarchies are always unstable. Markets shift. Boards reorganize. Partners get pushed out at fifty-five. Hospital departments change with every new chief executive.
Erik Erikson named the developmental cost seventy-five years ago. He called it stagnation. The forty-seven-year-old who has won every external game and stopped generating internally is in Erikson’s clinical category, not a metaphor [3]. The Aggressive-dominant operator wins the climb and stalls when he gets there.
The Hollow Win
The cost builds up quietly over decades. The data has names.
Steptoe, Deaton, and Stone looked at Gallup data from 160 countries and found a U-shaped curve for well-being. The lowest point is ages 45 to 54 in high-income English-speaking countries [4]. The time of peak organizational seniority matches the lowest point of personal experience.
Hedonic adaptation adds to this. In the classic 1978 study by Brickman, Coates, and Janoff-Bulman, both recent lottery winners and recent accident-paralysis victims returned toward baseline well-being within months [5]. The next title doesn’t really change things.
For me, the 1996 Kasser and Ryan paper stands out most. Adults who put extrinsic goals (financial success, image, social recognition) above intrinsic ones (self-acceptance, affiliation, community feeling) reported lower energy and more physical symptoms [6]. You can win the game and still lose your health, your relationships, and your sense of self the next morning.
Envy keeps coming up. Richard Smith and Sung Hee Kim defined it as feeling inferior, hostile, and resentful when someone else has something you want. Environments where people compare status (like partner tracks, boardrooms, or surgical conferences) make it worse [7]. The people you envy show you where you’re still keeping score.
Nora Volkow’s PET scans showed that repeated dopamine hits lower D2 receptors, and the reduction lasts for months [8]. Anna Lembke at Stanford described the pleasure-pain seesaw in her 2021 book: the more pleasure you get, the more pain you borrow from the future [9]. Wins bring less pleasure as time goes on. This holds for the drink, the deal, and the screen.
What Generative Drive Produces
The Harvard Grant Study started in 1938 with 268 sophomore men and ran for over seventy years. George Vaillant, who led the study from 1972 to 2004, reported in 2012 that the warmth of relationships at age 47 was a stronger predictor of flourishing later in life than income, social class, or IQ [10]. The usual Aggressive drive scorecards (salary, rank, cognitive ability) were measured and found less important.
Robert Waldinger, who leads the study now, has made this point many times: the quality of relationships at age 50 predicts physical health at age 80 better than cholesterol levels do [11]. Investments in the Generative drive add up over time. Aggressive drive scorecards don’t.
This idea has been measured directly. Dan McAdams’ Loyola Generativity Scale, validated for over thirty years, links generativity scores to life satisfaction, coherence, and meaning [12]. Generativity is an outcome, not just a value.
A 2016 meta-analysis of 10 studies and 136,265 people found that having a higher sense of purpose in life was associated with a 17% lower risk of death from any cause (RR 0.83, 95% CI 0.75-0.91) [13]. A 2019 JAMA Network Open study of 6,985 adults over 50 found that those with the lowest sense of purpose had more than twice the four-year mortality risk compared to those with the highest (HR 2.43, 95% CI 1.57-3.75) [14]. The Generative drive helps you live longer.
These ideas aren’t new. Deci and Ryan’s Self-Determination Theory lists autonomy, competence, and relatedness as the three basic psychological needs that predict well-being across cultures [15]. Csikszentmihalyi described flow as the state where skill meets challenge, creating lasting satisfaction unlike passive pleasure [16]. Frankl’s clinical observation from the camps, that the main human motivation is the will to meaning, underlies all of this [17].
This structure is older than any of us reading this.
The Upward ARC
This belongs in the Capacity pillar of my Upward ARC framework, the long arc of what you can know, decide, and become over thirty years. The second part is Recover. An Aggressive-dominant system runs on constant stress, and no amount of vacation, retreat, or executive coaching can fix that after the fact. The real decision about your system comes before any other change you try to make.
Try This Today
Five protocols. They cost time, not money. You don’t need a coach or therapist for any of them.
The Three-Drive Inventory. Sit down with a notepad and look back at the last ninety days. Make three columns: Generative, Aggressive, Pleasure. Where did your hours, attention, and energy actually go? Be specific. Not just “leadership work,” but “the board prep that was really about not losing the chair.” Not just “client time,” but “the call I took on the holiday because I couldn’t stand the idea of someone else handling it.” The unbalanced output is your audit. Most senior leaders find the Generative column is only ten to twenty percent of the page.
The Morning-After Test. Pick your three biggest wins from the past year. Without overthinking, write down how each one actually felt the next morning. If it felt flat, joyless, or like “what’s next,” that’s the Aggressive drive at work. Generative wins are remembered with warmth, not just relief. The pattern across your three wins is your audit.
The Generative Slot. Set aside a recurring ninety-minute slot each week for something that’s only about contributing or creating. Teach a mentee who can’t promote you, write something, or build something for someone who won’t return the favor. This slot is sacred and doesn’t move for your calendar. After eight weeks, run the Morning-After Test on this slot and compare it to your Aggressive-drive wins.
The Envy Audit. List the five most recent times you felt envy. Name the person, what they had, and what you felt. Conti says envy is the Aggressive drive without a chance to win. Your list shows where you’re still keeping score and which Generative slot might be missing from your week.
The Two Cupboards. Take twenty minutes with just paper, no devices. Write down five things you’d still want to do if no one ever knew. Then list five things you spend a lot of time on that you’d stop tomorrow if no one ever saw. The gap between these lists shows who’s really running your life.
Back to the Terrace
There were nine men at the table on the terrace: the chiefs of surgery, the partners, and the man with the brain tumor. None of them got there without the trait my coach drilled into me back in 1996. But none of them were using it tonight.
In a healthy system, the Generative drive comes before the Aggressive drive. The Aggressive drive doesn’t disappear, but the order just changes. The surgeon who refilled the wine glass before his own is the same one who runs his department by Monday morning. The ability to take the hill is still there. It just isn’t in charge on a Friday night in Malta.
The leaders who age well, exit well, and enjoy what they built are the ones who do this audit at forty-seven, not sixty-seven. The Aggressive drive won’t give up control on its own. You have to move it.
For most of us, the climb picked for this trait so thoroughly that we mistake it for our character. That mistake matters. The Aggressive drive is just one of three, and it shouldn’t be in charge of any of us.
The friend at the end of the table laughs at something. The surgeon next to him passes him a piece of bread. The protocols above are a deliberate way back to what these nine men already had on Friday night.
Stay healthy.
Andre
PS: If you read this and thought of a peer who has everything but feels nothing, please forward it to them. That’s how this newsletter grows, and it’s the only way I want it to.
References
[1] Conti, P. (Guest), & Huberman, A. (Host). (2023, September). Guest series: Dr. Paul Conti on mental health [Four-part audio podcast series]. Huberman Lab. https://www.hubermanlab.com/episode/guest-series-dr-paul-conti-how-to-understand-and-assess-your-mental-health
[2] Sapolsky, R. M. (2005). The influence of social hierarchy on primate health. Science, 308(5722), 648-652. https://doi.org/10.1126/science.1106477
[3] Erikson, E. H. (1950). Childhood and society. W. W. Norton.
[4] Steptoe, A., Deaton, A., & Stone, A. A. (2015). Subjective wellbeing, health, and ageing. The Lancet, 385(9968), 640-648. https://doi.org/10.1016/S0140-6736(13)61489-0
[5] Brickman, P., Coates, D., & Janoff-Bulman, R. (1978). Lottery winners and accident victims: Is happiness relative? Journal of Personality and Social Psychology, 36(8), 917-927. https://doi.org/10.1037/0022-3514.36.8.917
[6] Kasser, T., & Ryan, R. M. (1996). Further examining the American dream: Differential correlates of intrinsic and extrinsic goals. Personality and Social Psychology Bulletin, 22(3), 280-287. https://doi.org/10.1177/0146167296223006
[7] Smith, R. H., & Kim, S. H. (2007). Comprehending envy. Psychological Bulletin, 133(1), 46-64. https://doi.org/10.1037/0033-2909.133.1.46
[8] Volkow, N. D., Fowler, J. S., Wang, G. J., & Swanson, J. M. (2004). Dopamine in drug abuse and addiction: Results from imaging studies and treatment implications. Molecular Psychiatry, 9(6), 557-569. https://doi.org/10.1038/sj.mp.4001507
[9] Lembke, A. (2021). Dopamine nation: Finding balance in the age of indulgence. Dutton.
[10] Vaillant, G. E. (2012). Triumphs of experience: The men of the Harvard Grant Study. Belknap Press of Harvard University Press.
[11] Waldinger, R. J., & Schulz, M. S. (2023). The good life: Lessons from the world’s longest scientific study of happiness. Simon & Schuster.
[12] McAdams, D. P., & de St. Aubin, E. (1992). A theory of generativity and its assessment through self-report, behavioral acts, and narrative themes in autobiography. Journal of Personality and Social Psychology, 62(6), 1003-1015. https://doi.org/10.1037/0022-3514.62.6.1003
[13] Cohen, R., Bavishi, C., & Rozanski, A. (2016). Purpose in life and its relationship to all-cause mortality and cardiovascular events: A meta-analysis. Psychosomatic Medicine, 78(2), 122-133. https://doi.org/10.1097/PSY.0000000000000274
[14] Alimujiang, A., Wiensch, A., Boss, J., Fleischer, N. L., Mondul, A. M., McLean, K., Mukherjee, B., & Pearce, C. L. (2019). Association between life purpose and mortality among US adults older than 50 years. JAMA Network Open, 2(5), e194270. https://doi.org/10.1001/jamanetworkopen.2019.4270
[15] Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227-268. https://doi.org/10.1207/S15327965PLI1104_01
[16] Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. Harper & Row.
[17] Frankl, V. E. (2006). Man’s search for meaning (I. Lasch, Trans.). Beacon Press. (Original work published 1946)
A note for new readers:
I’m a trained reconstructive facial surgeon, medical doctor, and dentist. Before launching this newsletter, I had a varied career: competitive freestyle wrestler, management consultant (McKinsey), entrepreneur (Zocdoc, Thermondo, and docdre ventures), and corporate executive (Sandoz). Today, I’m a Managing Director and Partner at BCG.
Husband of one. Father of three. Split between Berlin’s urban pulse and our Baltic Sea retreat. I’d rather be moving than sitting. Not just hobbies. Research. My body is my primary laboratory; I’ve been conducting experiments for decades.
If this is your first time here, welcome. I’m excited to share what I’ve learned and will continue to learn with you.
DISCLAIMER:
Let’s get one thing straight: None of this, whether text, graphics, images, or anything else, is medical or health advice. This newsletter is here to inform, educate, and (hopefully) entertain you, not to diagnose or treat you.
Yes, I’m a trained medical doctor and dentist. No, I’m not your doctor. The content here isn’t a replacement for professional medical advice, diagnosis, or treatment.
If you have questions about your health, talk to your physician or a qualified health professional. Don’t ignore their advice or delay getting care because of something you read in The Upward ARC. Be smart. Do your research. And, as always, take care of yourself.