Tag Archives: support

More can be done to help people who consult doctors

In general practice patients generally present with undifferentiated conditions. People come for help with a cough and not ‘pneumonia’, back pain and not ‘metastatic prostatic cancer’, fatigue and ‘not diabetes’. In a study published in 2015 it was reported that a diagnosis is not established in 36% of patients with health problems. According to the research team half of the symptoms were expected to resolve or persist as ‘medically unexplained’. In their summary the team concludes that:

The study highlights the need for a professional and scientific approach to symptoms as a phenomenon in its own right. Rosendal et al

We also know that the commonest symptoms relate to the musculoskeletal system, respiratory system and the digestive tract. As long ago as 1984 Gordon Waddell and colleagues made a similar point in the BMJ :

The amount of treatment received by 380 patients with backache was found to have been influenced more by their distress and illness behaviour than by the actual physical disease. Patients showing a large amount of inappropriate illness behaviour had received significantly more treatment (p <0 001).

They concluded:

We know that a standard medical history and examination provide a wealth of information not only about the disease from which the patient is suffering but also about how that particular person is reacting to and coping with his or her illness. What is necessary now is to devote as much time and effort to the study and understanding of illness behaviour as we do at present to the investigation of physical disease. Only thus can we put the art of medicine on to a sound scientific basis.

Decades later these words are prophetic and we find that the thrust of research is on the diagnosis and treatment of specific pathology rather than on how to help people to cope with persistent back pain, acute cough or ill defined abdominal pain. This continues to be a bone of contention between doctors and patients as was illustrated in a classic paper by Joe Kai writing about the management of illness in preschool children in general practice:

Parents expressed a need for more information about children’s illness. Advice about the management of common symptoms was insufficient. They sought explanation and detail that was specific and practical to help them make decisions about the likely cause of an illness, how to assess severity, and when to seek professional advice. They wanted to know of any implications of the illness or its treatment and the potential for prevention in the future. Most thought that being more informed would reduce rather than increase their anxiety.

In a literature review published in 2002 in the BJGP Hay and Wilson charted the progress of children under 4 who develop an acute cough:

At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia.

The authors conclude that:

Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult.

By implication, as well as knowing when and how to investigate symptoms, it would help patients if doctors also routinely communicated the natural history of the commonest symptoms including and especially:

  • Acute cough
  • Acute low back pain
  • Rash
  • Depression
  • Sprain /strain

For example it has been demonstrated that the experience of individual doctors on this issue is unreliable. Writing on acute low back pain researchers from New Zealand suggests that 91% of patients stop consulting their doctor at 3 months after the pain starts and long before their symptoms have resolved. Also that only 1:5 patients are free of pain or disability one year after an acute episode of low back pain.

Picture by Tina Franklin

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto

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

Profiting from vanity- they may be targeting someone you love.

Where I live you’d be forgiven for thinking that you will be reported for child abuse if your teenager has less than perfectly straight teeth. Kids are growing up believing they need to be physically perfect.  So when the first crop of zits appears there is a hasty and often expensive trip to the chemist. Treating acne is a $3 billion industry in the United States alone.

..but i just feel so ugly when i see pretty girls with perfect skin around me.. it just makes me feel terribly disgusting, honestly. like i’m less of a person. it’s not fair. at my age there’s so much pressure to look beautiful constantly. even though i know most people don’t care how good you look a lot of them are secretly judging inside… everyone does it, even me..Nyla

Those in the age group 15-24 account for 7.6%  of consultations in general practice. Significant or life limiting pathology is unlikely in this age group but for many these meetings with their doctor will set the tone for a life long relationship with their main healthcare provider. For young people acne and eczema are the reason for almost one in three consultations with a GP. Sadly it has been reported that some teenagers get a very poor deal when they pluck up the courage to see a doctor:

It’s not that he doesn’t listen … sometimes he doesn’t fully comprehend that he’s talking in a way you can’t understand … it would help if they talked to teenagers. ( As reported by Jacobson et al in the BJGP)

This could be a missed opportunity to forge a relationship with the patient. If you are a doctor it may be worthwhile rehearsing a lucid explanation of common problems presented to you, including and especially acne. There is a bewildering array of opinions on this problem. Indeed the conclusion of research on this topic was that the majority of young people are getting information from non physician sources and there may be a need to evaluate the resources they are using to make sure they are receiving appropriate, helpful information. That includes parents who would rather their teenager would learn to live with her spots and expect you to endorse that view.

For those who want a ‘cure’ the opportunity for to profit from their distress makes them vulnerable to the most unscrupulous practices. $3 billion USD represents a substantial market for lotions, potions and diets that don’t work.

Substantial numbers of those surveyed had ideas about cause, treatment, and prognosis that might adversely affect therapy. Rasmussen and Smith

The truth is acne is a manageable condition, it’s just a matter of finding a treatment that works for an individual. For most people, it may take few attempts at find something that works. For some, over-the-counter topical creams are fine, for others, oral antibiotics or hormonal treatments work better, and yet others only respond to drugs prescribed by a dermatologist, with multiple courses required in relatively rare circumstances. The goal of having clear (or at least totally acceptable) skin is not unreasonable. This is a teachable moment in the interaction with young people.

Picture by Caitlin Regan

Common sense vs. miracle cures

I’ve seen this person, or someone like her many times before. On that occasion it was a demand for phentermine but it could have been antibiotics, ‘blood tests’, a ‘whole body scan’, benzodiazepines or opiates .

My doctor has prescribed it before. I need it again. So I just need a repeat script.

At a guess she had a BMI just shy of 30 and I noted that she had been prescribed this drug intermittently for a couple of years. She made it clear there was no room for discussion or argument. She had taken the day off work and wanted to get her diet underway. She wasn’t really interested in my opinion. If I’d prescribe it she’d leave. I explained politely that I don’t prescribe this drug (even though I could). I don’t believe it works and could actually harm her. But she persisted:

My professor prescribes it for me

In other words

What do you know about it? You’re ‘only’ a doctor.

I could explain lots of reasons why she shouldn’t be taking this drug. Phentermine is an amphetamine derivative that is used as an anti obesity agent it was approved by the US FDA in 1959 for short term treatment of obesity. It is the most commonly used anti-obesity drug on the US market and many US bariatric physicians use phentermine long term, ignoring the FDA guidelines that it be used for three months or less.

In a trial published in the British Medical Journal in 1968 it was concluded that phentermine has an anorectic effect ‘compared to placebo’. However according to a systematic review published in 2014:

No obesity medication has been shown to reduce cardiovascular morbidity or mortality. Additional studies are needed to determine the long-term health effects of obesity medications in large and diverse patient populations. JAMA

Like so many miracle cures discovered or unveiled decades ago we now know a bit more. Phentermine has been associated with psychosis. But there is precious little else to indicate major problems in the literature and the drug is still listed as available to prescribe. However patient experience is another matter:

I lost about 20 kg’s on [Phentermine] over about 6 months. I didn’t have any of the shaky or jittery, but these are common side effects. Even though my appetite was much less then it normally would be, I made a conscious effort to eat three small meals a day and a few snacks. I Used it in conjunction with a calorie tracker plus exercised. It can make the weight drop off quickly but if you don’t make the steps to eat correctly and exercise you can pick it up weight plus some again when you stop taking the tablets. Glowworm80

And another:

However, there are side effects. Lots of people say it makes their heart feel “racy”. This has not happened to me, but I suffered terrible insomnia. I wasn’t able to sleep before 3am in the morning, just lying in bed with thoughts racing around a million miles an hour. But then when you get up and take the next day’s pill, you get energised and you don’t feel like you’ve only had three hours sleep.

You can see how ridiculous this all is … eating next to nothing, sleeping only three hours a night but feeling no hunger and having boudless energy. It is not something that your body will thank you for in the long run. peckingbird

And this one:

I am sorry to say but I think any doctor who prescribes [Phentermine] as a first choice treatment for weight issues is being negligent. I really do understand the attraction when weight is needed to be lost quickly BUT..

I know many people who’ve taken it ( it was very readily available back in the 90s ) they have lost varying amounts of weight and have had varying side effects…some really dangerous and not one of them has maintained their weight loss beyond a couple of months after ceasing the drug. Soontobegran

This has also been my experience when I’ve prescribed it for patients in the past so I won’t prescribe it now. We need to exercise our right to refuse to prescribe treatments that promise more than they can deliver because they rarely do. We don’t need to wait for research evidence to catch up with common sense.

With regard to ‘diet pills’ I agree with this:

The allure of a pill – whether pharmaceutical or nutraceutical – that allows one to lose weight without requiring behavioural changes at the dinner table or in the gym is irresistible. a burgeoning market for both prescription and over-the-counter diet pills exists. Unfortunately to date, the dream of a thin-pill has largely failed to materialise due to unrealised efficacy, safety or both. Mark K Huntington & Roger A Shewmake

Picture by Baker County Tourism

Why people will sack a plumber but won’t sue their doctor

Everyday somebody somewhere summons a plumber. The drain is blocked, the boiler isn’t working, there’s a leak under the sink. The problem is obvious the solution is technical and everyone knows when the job is done. If it’s not fixed asap the plumber is sacked.

That’s rarely what it’s like in medicine. Not everything is a blockage or a break. Not everything can be fixed by sitting quietly with a tool box and following the instructions in the manual.

Many of the commonest problems in healthcare don’t have an easy fix.

  1.  The pain of ‘tennis elbow’ can last for months despite treatment

Patients with tennis elbow can be reassured that most cases will improve in the long term when given information and ergonomic advice about their condition. Bassett et al.

2. Plantar warts don’t always respond to cryotherapy

Little evidence exists for the efficacy of cryotherapy and no consistent evidence for the efficacy of all the other treatments reviewed. Gibbs et al

3. Lung cancer is incurable in most cases

Lung cancer is the main cancer in the world today, whether considered in terms of numbers of cases (1.35 million) or deaths (1.18 million), because of the high case fatality (ratio of mortality to incidence, 0.87). Parkin et al. 

4. Anti hypertensives aren’t guaranteed to prevent stroke

Our analysis indicated that the absolute benefits of antihypertensive therapy depended on BP as well as the presence or absence of additional cardiovascular disease risk factors and the presence or absence of preexisting clinical cardiovascular disease or target organ damage. Ogden et al

5. Mild depression can be hard to treat

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. Fournier et al 

6. There is no cure for the common cold ( You don’t need a link for this)

These and most other problems in healthcare cannot be ‘fixed’. They can be diagnosed and they can be ‘managed’ but they can’t be fixed in the way that faulty plumbing can be fixed. Therefore that queue of people in the waiting room is saying something more than ‘I’m here to be fixed.’ Patients are saying:

  1. I am in pain
  2. I am anxious
  3. I am unhappy
  4. I am bored
  5. I am angry
  6. I am confused
  7. I am lonely
  8. I don’t like my job
  9. I can’t pay my bills
  10. I need tablets or surgery

The job of the doctor is to work out which and then to fix what can be fixed and help the patient to live with the rest until their perspective or their circumstances change.

  1. Most people won’t take their tablets as prescribed.

    Because non-compliance remains a major health care problem, high quality research studies are needed to assess these aspects and systematic reviews are required to investigate compliance-enhancing inteventions. Let us hope that the need will be met by 2031. Vermeire et al 

  2. Most people won’t benefit substantially from health promotion advice.

Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies. Williams et al

3. Most people get better in spite of treatment and not because of it.

Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximise potential markets. Moynihan et al

But then most people will be deeply grateful to their family doctor because they don’t have to respond a certain way to be treated with respect and they don’t expect a ‘cure’ and won’t ask for their money back when things don’t work out. The doctor’s role is to be there, to encourage, to educate, to accept and to walk with their patient through all the challenges that life has to offer.

Picture by Vicki

There is no curriculum for kindness

For months, my wife had been worried about the mole. I couldn’t see anything wrong with it but then it was on my back and I was peering at it through a mirror. In the end, she put the job of getting it examined by a doctor into my diary and it became ‘urgent and important’.

I decided I’d ask my colleague in the office next door if he could recommend a dermatologist.

Do you want me to take a look?

I hated to impose, it seemed hardly worth wasting a surgeon’s time looking at something I was convinced was benign.

Without a second thought, he bounced out of his chair and headed to his car appearing a moment later with a head-mounted magnifier.

It looks benign. However I have three rules with these things. We remove it if your wife is worried about it, if you are worried about it or if I’m worried about it. It’s a five-minute job. We can’t be sure until it’s sent to the lab. But you know that.

He smiled kindly. It was a small courtesy to a colleague,  but a telling example of how a man you had been a surgeon all his life could still be spontaneously kind. His rule made excellent sense. This behaviour is not in any medical textbook. It’s not recognised as an ‘innovation’ that can improve outcomes. It’s just plain old-fashioned, good-natured thoughtfulness. It doesn’t require a grant or a special piece of equipment or anyone’s approval. It makes all the difference to all of us every day. It’s the sort of thing that speaks of vocation. I’m grateful that my colleague works with me, he is a wonderful communicator and that matters when you are training future doctors.

Picture by British Red Cross

Some experiences recalibrate the patient’s response to health practitioner support

6025359063_81a0b67b4c_zIn a review of the impact of breast cancer on women’s lives we reported one woman’s perspective on her relationship with her partner as reported to her Specialist Breast Cancer Nurse:

He’s slowly letting go. And we had a wee talk yesterday actually because [Name]’s very boy like. Never wanted children, never wanted commitment that’s why it’s, I’m more of a mother than anything to him and he spends a lot of time playing games on the video and doesn’t really do a lot around the house and I just said to yesterday, I said this is quite frustrating for me because with what I’ve been through I want to live life and sitting around here having somebody play video games is just not really doing it for me. Jiwa et al

The experience of breast cancer had altered her view on something she had taken for granted. Pre-cancer was very different to post-cancer. A subsequent paper concluded that:

In the absence of cancer specialists, in years 3, 4 and 5 following diagnosis, Australian women would prefer to have their routine breast cancer follow-up provided by a Breast Physician (or a Breast Cancer Nurse) in a dedicated local breast cancer clinic, rather than with their local General Practitioner. Bessen et al

What patient experience drives this preference when nationally experts in cancer care have been actively promoting shared care between GPs and specialists?

We speculated that it is the relationship with the  Breast Cancer Nurse (BCN) from diagnosis through treatment and beyond. At this time in most cases, the GP is hardly involved at all. Our data suggested that if the approach to patients in the period following active treatment was limited to discussing physical symptoms and possible side effects of adjuvant therapies then there will be a lost opportunity to help patients to adjust to the experience of breast cancer. From our data one can only speculate whether this would lead to psychological, social or physical problems or whether patients would find other sources of help. However, the importance of the BCN who has the experience and resources to support the woman throughout the process of readjustment but can also recognise the significance of clinical changes in breast tissue is a critical element of any follow-up protocol. That does not mean to say it can’t be her GP, but the conclusion of research with patients is that often it is not.

Overall, BCNs play an important role in facilitating the transition of patients by supporting the woman in adjustment to a new self-image and bodily functioning. The BCN accompanies each woman through this phase in her life while supporting a new narrative, promoting her ‘rebirth’ as someone with views that have altered significantly after the diagnosis of cancer.

Breast cancer along with many other conditions where the patient is subject to treatment to combat a potentially life-limiting pathology changes the patient’s perspective forever. In crafting support for such patients, it may be crucial to consider what the patient has experienced and with whom and not what would suit health care providers to offer in the way of support. The follow up regimen has to be tailored to the context. That word context again!

Picture by Liz West

No we can’t

7621106098_6732c0ca6f_z

Oh yes doctor, we would like to have you present at our conference. In fact we would like you to run a three hour workshop and do a plenary. And sorry no we don’t pay speakers. We offer budget travel and basic accommodation.

I couldn’t believe what I was hearing. The preparation for this would take weeks. According to the glossy brochure the conference was to be held at an expensive venue overseas and the delegates would be paying handsomely to attend. The young man who called me couldn’t see anything wrong with asking me to work on his business at the expense of my employer in order to make a profit for his company. My response as far as he was concerned was unexpected. Which means he was probably used to hearing:

Yes

Academics give it away for a plane ticket and a cheap hotel room. They are just so pleased to be noticed.

The word for 2016 has to be:

No

  • No to urgent and not important
  • No to someone else’s priorities
  • No to time wasters
  • No to projects that don’t serve the mission
  • No to lack of self respect

If you are being asked, as you will be daily, to give up your time and pay an opportunity cost to be distracted then your boss has the right to ask difficult questions at your annual appraisal.

  • What did you accomplish today?
  • How does this work towards the mission of your team?
  • What tangible can you show when you reflect on progress this week?

Learn to say

No.

Here are some different ways to say it. Practice today. Say it politely but say it emphatically.

No, Nein (German), Non ( French), Hapana (Swahili), Naheen ( Hindi).

If you practice it judiciously then you are less likely to hear it said to you.

Picture by Michael Sissons