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How can doctors remain the health practitioner of choice?

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You work as a checkout assistant at a supermarket. It’s Thursday. You’ve got a sore throat. It started a few days ago. You’re sneezing, you’re tired, you’ve got a headache. You’ve taken paracetamol already today it didn’t take away all the discomfort you still feel dreadful. You have several problems.

You want to feel better. Secretly you may be concerned that this is more than just a cold. You want to reassure the people that you are going to be well again in a few days. You want people to understand and accept that you are not functioning at your best at the moment. You want it all now not next week when you might be better or worse.

You may want information but you probably also want to have your discomfort validated and acknowledged. You’ve got some choices to make. You can try and get a doctor’s appointment. You can Google the symptoms and treatment. You can go to the local pharmacy or to your favourite alternative health practitioner. You can also try the emergency department. What you choose will depend on your previous experience of a similar episode but also on what your friends and or family suggest.

Upper respiratory tract infections are among the commonest reasons that patients seek the services of a general practitioner in Australia. It’s a presenting problem in one in twenty consultations. In the majority of cases these infections are viral and don’t require a prescription from a registered medical practitioner.

On the other hand there may be a financial cost to attending a doctor. You will need to take some or all of the day off and you may be required to queue despite you physical discomfort and it is more than likely that the doctor will tell you what everyone has already suggested that you will probably feel better in a few days. Whether you consider it useful to attend the doctor will depend on whether your needs were met last time. How do you feel at the end of the consultation? Did you feel that your visit was welcomed and that you were treated sympathetically? Did the doctor listen to you? Did they examine you? How did they convey the news that there isn’t any curative treatment available? How did they make you feel about the decision to make an appointment at the practice?

If we consider that such ‘trivial’ problems could be managed by another healthcare practitioner then we are asking for one in twenty encounters in practice to cease. How do we convey this message to our patients.

Colds are generally mild and shortlived, so there’s usually no need to see your GP if you think you have one. You should just rest at home and use painkillers and other remedies to relieve your symptoms until you’re feeling better. NHS Choices

The challenge is that most of what the patient is likely to present with as a new problem is similar: bronchiolitis, gastroenteritis, sprain/ strain, viral disease, contact dermatitis, back pain, bursitis, solar keratosis/ sunburn, tenosynovitis, tonsillitis, vaccination. These conditions or problems form a substantial chunk of the workload.

What can doctors add to these encounters that would make them a worthwhile experience for patients? Not just what might be ‘evidence based’ but also perceived as useful by the patient? Experiences that will retain the doctor and not a pharmacist, nurse, chiropractor, naturopath, homeopath, Dr. Google or ‘McDoctor-dial-a-doc’ as the healthcare practitioner of choice. In Australia doctors have typically 15 minutes. Here are some possible value adds:

  1. Offer advice on weight loss and exercise
  2. Advise on smoking cessation
  3. Review the patient’s medication
  4. Promote cancer screening
  5. Advise on vaccinations
  6. Examine the patient
  7. Document any possible risk factors for chronic illness
  8. All of the above

Back to the checkout assistant who is feeling dreadful, wants more than anything to go home after sitting in your waiting room, nursing a fever and a runny nose. It’s up to you of course but it I know which of the above I would want my doctor to do at that time. Patients tell it as they’ve experienced it and research has suggested what they are willing to pay for.

Picture by Tina Franklin

Practitioner income as a function of Freakonomics

According to headlines this year more than one in three GPs in Australia report feeling somewhat or very dissatisfied with their income. Two things determine health practitioner income:

  1. What is a (funder / government / insurer) willing to pay?
  2. What is a (patient / customer / client) willing to contribute?

What is beyond doubt is that when it comes to their pet’s healthcare the Australian public is very willing to pay. In fact Australians would alter their spending habits rather than compromise their pet’s quality of life.

Of the 2,500 Australians, aged between 18 and 65 that were surveyed in the 2015 Financial Health Barometer, only 14 per cent of pet owners would reduce spending on their pets if their income dropped Remarkably, almost half (48 per cent) of respondents would take steps to minimise their power usage. We’d be more likely to reduce spending on essentials (47 per cent), switch to using cheaper products (35 per cent) or look for additional work (16 per cent) rather than curb spending on our furry friends. Hayley Williams.

Similarly spending on beauty treatments is remarkable:

The online survey of close to 1300 Australian women was conducted by Galaxy Research and commissioned by at-home hair removal brand Veet.
And, while 10 per cent of the women surveyed spent $5000 on average and and almost 60 hours in the beauty salon annually, 40 per cent admitted to putting their beauty regimens ahead of sleeping, shopping and their social life, with 4 per cent of those women also choosing a salon visit over their sex lives.

In contrast national statistics document that a significant proportion of Australians are reticent to seek healthcare because of the perceived cost. It was not surprising that a proposed $7 co-payment proposal for general practitioner visits in Australia was dumped before it was enacted.  It is evident that some doctors get paid far more than others. Secondly some parts of the country attract more doctors but as a general rule where there is a scarcity, by dint of geography or specialisation, it is more likely that doctors will earn more.

What people are willing to pay for health care is a function of economics, or perhaps “Freaknonomics” (study of economics based on the principle of incentives.) From this perspective “incentives matter.” Consumers try to maximize total satisfaction, while providers try to maximize profits. Whenever there are a lot of people willing and able to perform a job, that job doesn’t pay well. In a capitalist society, intense competition will drive prices down. When a technological advance occurs, it results in a shift of the supply curve to the right. All other things equal, this will lower the equilibrium price of a good, which then increases demand. Both producers and consumers need to be fully informed regarding their consumption or production decisions for a market to be efficient.

So how might this apply to primary care? 

  1. There are more doctors per head of population than ever before- in other words more people willing and able to perform the job- especially in primary care.
  2. There is a global trend in developed economies for “alternative providers” for primary care services- including vaccination, cancer screening and treatment of ‘minor’ illnesses.
  3. Technology offers new ways to ‘consult’ a practitioner other than by having practitioner and patient in the same room.
  4. Because of the internet doctors no longer hold the monopoly on information.

So doctors’ incomes in primary care experience downward pressure because suppliers of the services are increasing. We might therefore consider what people would consider paying for a consultation at a doctors’ clinic. Research published in 2008 (Annals of Fam Med) offers one perspective:

  • Overall, patients were willing to pay the most for a thorough physical examination ($40.87).
  • The next most valued attributes of care were seeing a physician who knew them well ($12.18),
  • Seeing a physician with a friendly manner ($8.50),
  • Having a reduction in waiting time of 1 day ($7.22), and
  • Having flexibility of appointment times ($6.71).
  • Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82).

It seems that two sectors (Pets and Beauty) appear to have no difficulty with their income. What might they have to offer by way of advice?

  1. The art of creating added value starts with the ability to see your business through the eyes of your customers.
  2. Although the debate over whether the customer is always right (or not!) continues, lack of customer satisfaction is a sure-fire way to keep people from coming back.
  3. Implement marketing models into your strategy.
  4. Most importantly, memorable customer experience models aim to deliver unexpected intangible value that cannot be packaged or sold. This includes personalized service, attention to detail, and showing a sense of urgency to address concerns as they arise.
  5. Whether it’s a free guide, a printable PDF, or a company branded calendar, free resources are a great way to create added value and showcase your brand’s ability to offer ‘a little something extra’ to customers.

In the case of healthcare the ‘customer’ is not just the patient but also the pay master. These ideas may need to be translated for this sector. In many cases it probably already has been. However for others there is something to learn from how successful businesses add value that translate into better rewards.

Picture by Pexels

An illness is never minor when you’re ill

After 20 years in practice I’d never seen one of these in my career. Until that day. It’s called a quinsy. Essentially an abscess deep in the throat. Not really surprising because according to a recent review:

Most patients with quinsy develop the condition rapidly, and many do not present with a respiratory tract infection to their GP first. BJGP

The incidence is estimated to range from 10-41 cases per 100,000 per year. It’s unusual to see a case in practice. Given Australia’s 23 million people you’d expect an incidence of about 2,300 cases per year nationwide. Similarly I consulted a young child with nephrotic syndrome, similar incidence (3.6 per 100,000). Both cases were referred to hospital as emergencies. The odds of seeing one of these is in the same order of magnitude as being struck by lightening in your lifetime.

On the other hand in the same week I saw several people with:

I also saw a victim of domestic violence:

Just under half a million Australian women reported that they had experienced physical or sexual violence or sexual assault in the past 12 months. Domestic violence prevention centre.

And a drug seeker:

Australian GPs write more than 15 million prescriptions per year for drugs known to be misused, with the main prescription drugs misused currently being narcotic analgesics and benzodiazepines, as well as stimulants, barbiturates and other sedative–hypnotic agents. Martyres et al

So apart from quinsy and nephrotic syndrome (both of which I recognised) I spent most of my week managing conditions that didn’t need to be referred to specialists.  And yet the people who were offered reassurance or simple and effective treatment for their ailments were immensely grateful. Every day general practitioners provide this service to the community. They save lives by identifying people who need urgent care but much more than that they make the lives of the community so much more tolerable. There is no such thing as ‘minor illness’.

The last word has to be on pityriasis rosea:

I finally found out what the rashes on my back, arms, torso, and now my foot are. I have herolds patch too. I hate it! I can’t stop scratching. It took 1 hospital visit and a trip to my doctor to find out what this thing was. The doctor at the hospital thought the big round patch was a ringworm and he thought all the other small rashes that had just appeared was scabies. I was terrified..did some research on scabies and tried to treat that myself. Then I decided to just go to my doctor and he told me it wasn’t scabies…and showed me a picture of hereld’s patch. He knew what it was right off the bat. I guess there is no cure for it and it just goes away by itself. I just wish I could take something so I can stop scratching. SkinCell forum

Picture by Col.Sanders

Why general practitioners are crucial to the economy

The odds of experiencing an event that will descend you briefly into your own private hell are significant.

These odds are much greater than the odds of getting something that requires heroic intervention:

Good news = You are more likely to catch a cold, sprain an ankle or have a runny nose than suffer anything more serious.

Bad news = What happens if you get one of the aforementioned ‘minor illnesses’.  I am living with fractured ribs this week. This is what happens:

  • You are told there is no treatment and no definite recovery period.
  • You can’t tie your own shoe laces, take off your socks or dry your back after a shower.
  • You can’t push open doors.
  • You can’t get out of, our turn over, in bed.
  • You dare not sneeze or pick anything off the ground.
  • You get persistent headaches because of paravertebral muscle strain.

The pain will get worse before it gets better. So at first you might go to the emergency department (ED) because your family will insist. At the ED you will be X-rayed. You will be prescribed analgesia and advised to take time off.  A day or two later in increasing pain you will toy with the idea of going back to hospital just in case they’ve missed something.  The codeine will cause constipation making things worse. Some doctors will advise you to take tramol others will advise against it. A specialist might recommend intercostal nerve blocks (anything looks like a nail when you are armed with a hammer). The cost of getting medical attention will mount. What you will need the most is symptom relief and a greater sense of control. Your only hope is a good GP.

In desperation you might consult YouTube for any useful hints on how to recover. This person has clearly never experienced rib fractures. I hope no medical student thinks this is how to approach the examination of anyone with this condition. On the other hand this person clearly has.

Health economists tell us that the increased costs in the healthcare system are due to unnecessary tests and treatments.

On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago

You are at greater risk of ‘minor illness’ than any other illness. Yet we know that is when we are likely to request tests and treatments in the vain hope it will hasten the recovery. Good GPs  reduce this morbidity as well as the cost of caring for people when time is the only treatment.

This week we launched the Journal of Health Design. The scope of our journal is to support researchers who are developing innovations inspired by the patient experience of healthcare. This was also the week that the Royal Australian College of General Practitioners supported our team to conduct research that aims at supporting GPs in consultations with people with viral infections when antibiotics are not indicated.

Picture by Matt Pelletier

Why hardly any medical invention is better than a six inch wooden stick

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A timeless and effective innovation:

  • Can be deployed in any setting
  • Cheap and easily available
  • Familiar
  • Requires minimal training
  • Acceptable to all
  • Unobtrusive or at least does not impact negatively on the consultation
  • Changes how we feel

The best one yet is the humble tongue depressor. How does your gadget, gizmo or app compare?

I recall our then 14 year old returning from a visit to his GP.

Dad, he didn’t even examine me!

It seems the doctor did not look into his sore throat and somehow the patient felt ‘cheated’.

But son, it wouldn’t have made any difference if he did look in your throat, doctors can’t tell if a sore throat is cause by a virus or something else just by looking at it.

I know that dad but the ‘magic’ is in the examination.

That from a 14 year old! A few months later an older woman consulted me with the ‘worst sore throat ever!’ I took a history of what sounded like a upper respiratory tract infection and the examined her very unimpressive throat with said wooden spatula. As I turned away to put it in the bin she said:

There’s one more thing doctor. For the first time in ten years I haven’t been able to afford books for my kids going to school. So I’ve been working as a prostitute.

It is possible or even probable that she would have told me this anyway. However I posit that the an examination with a wooden spatula is a profoundly intimate act. It changes the dynamic in the consultation when your doctor is able to see your sore red throat, is able to notice what you had for your lunch, whether you clean and floss your teeth and smell your bad breath. These intimate details are not shared with everyone or even with our most trusted confidantes. Indeed breath odour has been associated with a very significant impact on self image:

…smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one’s own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one’s body image and self-confidence. McKeown

In that context further disclosures can follow an examination of the mouth in a way that can change the diagnosis and management.

That is a truly valuable innovation.

Picture by USMC archives

The failure to communicate is costing us billions

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The Weekend Australian headline today, Sunday 24th April 2016 declared that

Healthcare waste costs $20bn a year

According to the graph on the first page of the paper there were 105-110 General Practitioners (GPs) or specialists in 2004. Although the number of GPs per 100,000 population has remained static there are now more than 130 specialists per 100,000 people . Therefore the rising cost of waste in healthcare runs parallel to the increase in specialists in the population. The source is quoted as the Australian Commission on Safety and Quality in Health Care.

But there is nothing new about this story. This trend was demonstrated in previous decades. More primary care equals lower costs the formula isn’t complex. Reading the papers today we recall the late Barbara Starfield’s words:

Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.

The disappointing thing about the accompanying newspaper commentary was the suggestion that the solution is political. The journalistic analysis is that powerful lobby groups have managed to influence policy to the point where there is subsidised over servicing of the population. Specifically prostatectomies, colonoscopies, arthroscopies, cataract surgery, hysterectomies and CT scans.

In a country where general practice remains the gatekeeper to specialist services we need to figure out how we might be able to tackle the problem for the sake of the economy. The solution is to remain circumspect about another quick fix because we have learned that politics and the need to be popular with the electorate rarely delivers anything like a lasting solution.

In medicine people are referred or persuaded to have treatment or investigations and under the ‘big data’ is the story of ineffective consultations. One where either the patient is not examined or an adequate history taken, or where the risk and benefits are not explained to the patient in a way that informs the decision. After all if that were not the case which patient at very low risk would chose to have a colonoscopy?

What is the difference between managing a request for an antibiotic for a cold and managing a request for a CT scan for mechanical back pain? To those who are cynical about the chances of getting the message heard we might say wait. When there is sufficient pain the bureaucrats will beat a path to your door. There is no solution as effective as improving how we communicate with patients, anything else will paper over the hole, no the chasm, in the budget.

Picture by Christopher Blizzard.

Please don’t ask for my time as refusal may offend

In an article from the Economist, the authors advise that we appear to perceive ourselves as short of time. Every minute of the day can be filled ‘doing’ something or several things simultaneously, often badly. We are also increasingly wedded to the demands of our mobile devices. People spend time texting while eating, driving and even on the loo. In fact it is estimated that we spend one third of our waking hours interacting with our phone.

In an experiment carried out at the University of Toronto, two different groups of people were asked to listen to the same passage of music. Before the song, one group was asked to gauge their hourly wage. The participants who made this calculation ended up feeling less happy and more impatient while the music was playing. Participants reported experiencing greater impatience while listening to the music when prompted to think about their time in terms of money.

This has some important resonance in healthcare where practitioners who earn a living through fee for service may, and often do, become impatient about engaging with researchers or academics. This is a significant problem because in countries where primary care is the first port of call for most people we desperately need research to ensure that the service offered is both evidence based and cost effective. But what is the order priority: appointments with patients, results of tests, administrative paperwork, continuing medical education, family commitments, surveys or recruitment to research? There is an opportunity cost to all of these activities.

Research in primary care is challenging not least because as has been observed repeatedly it is very difficult to recruit participants to trials in primary care. Practitioners are not funded by the paymaster to do research. Costing the recruitment to adequately compensate for the time taken to seek informed consent is prohibitive and the medical defense organisations do not indemnify doctors to do research.

Therefore, it is often if not almost always, very challenging to conduct randomised clinical trials in that setting. Other methodologies, such as prospective observational studies may be more likely to yield data whilst at the same time acknowledging that this would not be classed as level one evidence. Nonetheless, we need to work within a paradigm in which neither patient nor practitioner is likely to participate or if they do attrition is substantial and threaten the validity and generalisability of the data.

We need more creative ways to test hypotheses and collect data in primary care. Methods that capture data from a substantial number of representative participants. Methods that generate a minimum disruption to the business of doctoring. Traditional research approaches are failing or are only really possible where doctors and patients have unlimited funded time. I don’t know where that is, meantime remain sceptical about results of trials that appear to have recruited and retained thousands of participants but where the practices were involved in a significant effort to recruit to research. In that scenario somebody has paid, always ask who and why.

Picture by M01229

Observations of healthcare workers may be better than big data

Apparently when a message is put alongside a cardboard cut-out of a person it is more likely to be noticed and actioned. How the message is relayed to the ‘customer’ matters. This has implications for the sort of results we seek in health care. I am sure the reader could think of many ways this observation can be deployed to improve outcomes in healthcare, just as retail and law enforcement organisations use the concept to communicate with their customers. For example, would you consider having a full sized cardboard representation of a doctor in your practice encouraging people to have their children immunized? Richard Wortley offers some other interesting insights and strategies for behaviour change albeit in the context of law enforcement. What healthcare needs is interventions and ideas, whatever their provenance.

The observations and insights of your staff and colleagues are often, if not always, more valid than so-called ‘big data’. Big data sets are often used for some other purpose (e.g. healthcare administration) and then extrapolated to understand why people are referred inappropriately or prescribed the wrong drugs. More often than not without reference to the people who collected the data in the first place. It is even more fashionable to ‘link’ this data to other information collected for yet another purpose ( e.g. cancer registry). The results may lead to dubious conclusions and wide-ranging policy changes endorsed by a professor or two who have never been on the shop floor, or at least not recently.

‘Big data’ may be easy to collect, despite the limitations of its validity, it offers substantial numbers for a statistician to ‘crunch’. National conferences are now themed on ‘big data’, there are substantial grants available to those who choose this ‘methodology’ for their research endeavours. Meanwhile, the local and contextualized reflections and observations of those delivering health care are seldom accorded the same credibility. The desire for a fast and cheap solution to the increasing cost of healthcare drives funders to throw dollars at anyone who promises a quick-fix and can cite a p-value.

Here the business literature may be relevant:

The study identified a number of factors that influence the success or inhibit progress in terms of performance and sustainable improvement. The findings identify what companies perceive to be inhibitors and enablers for sustainability, within 21 companies who have conducted process improvement (PI) activities using a common intervention approach…..The general and cultural nature of the identified enablers indicates that managers perceive progressing PI activities are reliant on a change of culture within their organisations in parallel with “up‐skilling” the technical knowledge of employees for change to be successfully enacted. The lack of specific processes to change culture, identified in the enablers, also indicates that managers do not know what to do to change their cultures or how best to deal with the inherently challenging and demanding nature of process improvement with shop floor operators. Rich and Bateman

Sounds like healthcare. Perhaps the methodologies deployed in successful care studies hint at a better approach. No big database was dissected in this example which resulted in sustained business performance in an Australian company:

Using data collected through in-depth interviews, the case study describes how the company progressed from an earlier initiative based on quality control to the present initiatives that emphasize customer focus, product development, and innovation. Several important insights are drawn from the case study, including the importance of aligning the quality programmes or initiatives with a clear strategic focus. Prajogo and Sohal

Stand by for the launch of a new academic forum which will focus on the patient experience as the driver of innovation.

Picture by Aranami

 

How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

Picture by Alyssa L. Miller

For best results next year leave the office now

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Let’s agree what success looks like at work. It’s simply ‘better outcomes for those you serve’. It’s about improving on what was done yesterday. Machines can ‘do’ many things but they can’t imagine. People can be made to work like machines but unlike machines their ‘parts’ can’t be replaced easily when things start to fail. However people can be replaced. If you exist to ‘do’ things that could be done more efficiently or more profitably you will be replaced perhaps not today or tomorrow but soon enough. If your boss doesn’t sack you, one day in the foreseeable future you will walk out when it all gets too much to bear.

So your real value in whatever you do is the ability to add value and to do that reliably and sustainably.

Think of a time when you landed that job, made that discovery, found that break through, solved that problem. Could it all have been different? What if you had failed that exam? What if you had succumbed to that virus? What if you hadn’t met that key partner? What if they hadn’t supported you? What if the funds hadn’t been available? What if you hadn’t attended that course or crossed that road? What if Fleming hadn’t gone on holiday or noticed that Petri dish?

Often described as a careless lab technician, Fleming returned from a two-week vacation to find that a mold had developed on an accidentally contaminated staphylococcus culture plate. Upon examination of the mold, he noticed that the culture prevented the growth of staphylococci. Endocrine today.

What if the egg containing your genes hadn’t been fertilised? Your life by statistical computation is a miracle.

If you go back 10 generations (250 years) the chance of you being born at all is at most 1 divided by 6 x 10100 or
1 in 60000000000000000000000000000000000 00000000000000000000000000 000000000000000000000000000000000000.
In gambling, even a chance of 1 to 100 is not worth a gamble. Hooge

You don’t really ‘do’ anything other than join the dots, but first you need to see the dots. There is nothing you have including life that couldn’t be taken from you in an instant.

At this time of year, for many people, there is an opportunity to invigorate that part of the brain that is the crucible of creativity. For best results flood the senses with new experiences; listen to new songs, read, taste different food and let your brain prepare to solve problems by making room for new ideas. De-clutter, let go the oars and do that for the sake of those you serve if not yourself. So say to your boss this is the most important thing you are doing for him this year- sharpening the saw.

Do you believe this sound conducted by Morricone is the product of a mind focused on the banal? You too have done some extraordinary things this year- big things, little things, all of which point to your potential to improve this world. What you believe about where the ideas come from doesn’t matter because they will continue to flow into our experience notwithstanding your convictions. What will matter to your boss in January is that you have an active problem solving capacity. So take a holiday. Enjoy!

Picture by Claus Rebler