What It’s Like To Start A Business

I received a letter from a fellow healthcare worker the other day.

She wrote to me regarding a patient of mine, demanding that I “do something”.  Her letter was, to be quite honest, rude and uncalled for.  She knew very well that I had already seen the patient, assessed the patient correctly and that the patient had the ability to make decisions regarding her own medical care.

This isn’t an uncommon occurrence.  I spend a significant part of my working day telling patients and other healthcare professionals that nothing needs to be done.  And that often doing nothing is more beneficial than doing something for the sake of doing it.

But why are patients and people in general like this?  Why, for example, does a patient with lower back pain for a grand total of two days turn up at my clinic demanding an urgent MRI scan, which would bring no benefit to the patient whatsoever?  Why do they get angry and upset when I explain that physiotherapy and lifestyle changes are the way forward?

I think there’s a simple answer:

The patient is worried that they are going to die*.

And who can blame them for having this outlook?  Most people from a young age have been conditioned to think that death is lurking right around the corner.

The thinking even in primary school was something along the lines of: “If you don’t do well in school, then you’ll end up without a job, then you’ll end up homeless and then you’ll die a sad and lonely death.”.

Of course for the people who made it through school and are not dead – which happens to be the majority of mankind – the above line of reasoning is clearly false.

Yet the same thinking often persists and manifests itself in absurd ways later on in other parts of  their life.

riskysport

This is not what it’s like to start a business

I think a lot of people avoid going into business for themselves due to this reason.  Even though it would be better for themselves, their family and those they serve to go it alone, they don’t.  Or worse, they say “someday”…

The fear of death manifests, in the form of being someone elses devoted employee for the whole of their healthy adult life.  “I’m not a risk taker”, they tell themselves.

Look, I get it.  It’s fine if you are truly happy as an employee.  What I can’t tolerate is when people make up BS excuses for not doing something with no logical reason.

So how to think about things?  How do you decide what is truly risky and what isn’t?

The Two Types of Risk

I believe that there are two types of risk.

  • Compound Risk

This is the type of risk which builds up over time and then ultimately does result in poor life outcomes such as bankruptcy and death.  Ironically people take these risks all the time without any consideration for their ultimate effect.

For example the decision to not exercise today, or the decision to just have that pizza instead of sticking to the diet.  These types of risk compound over time and then one day give you a heart attack or stroke.

  • Simple Risk

These are risks that can be calculated and taken with no hidden / compound effects.  If for example you decide to buy a car with cash you can easily calculate if you can afford it and what type of risk a reduction in your bank balance will lead to.

The problem is that these two types of risk often become conflated. 

People think that starting a business is a “compound risk” instead of a “simple risk”.  When in fact starting a business has a limited downside and a possible large upside.  It’s a calculated, simple risk.  

Or people think that “eating one more slice of pizza “is a “simple risk” and not a “compound risk”.  They think that one more slice of pizza or drinking one more alcoholic drink is no big deal.  They fail to realise how the risk compounds with time and that that “one more” may lead to an unpredictable heart attack somewhere in the future.

This conflation of the types of risk is what’s happening in the patients who have back pain demanding that “something has to be done”.  They don’t realise that when a doctor has competently assessed you and has ruled out “red flags”, which could indicate a serious underlying issue, that the risk will not compound.  It doesn’t matter if you’ve had the back pain for a day or a year.  If the clinical scenario has not changed then the risk is still a “simple risk” and will not “compound”.

Yes, physiotherapy and lifestyle change is still the way forward.

*Usually men and women alike tend to think that they have metastatic cancer if they have lower back pain.  They fail to realise that they have developed the pain because their body is trying to signal to them that they have poor muscle development (usually due to being overweight and inactive).

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Things Your Doctor Can’t Do…

Maybe one day I’ll hang this list in the waiting room of my clinic:

  • I can’t cure your cold 
  • I can’t give you antibiotics for your cold
  • I can’t give you antibiotics for your flu
  • I can’t give you antibiotics for your diarrhoea of two days 
  • I can’t give you antibiotics for sinus congestion
  • I can’t give you morphine for your back pain
  • I can’t cure your back pain if you don’t lose weight
  • I can’t help you lose weight if you don’t eat right and exercise
  • I can’t help you with your diabetes if you don’t lose weight, exercise and eat right
  • I can’t help you with your high blood pressure if you don’t lose weight, exercise and eat right
  • I can’t help you with your chronic pain if you don’t lose weight, exercise and eat right
  • I can’t help you if you lie and say you are exercising and eating right
  • I can’t help you with recurrent chest infections if you keep smoking
  • I can’t reverse your Lung Cancer which was a result of your smoking
  • I can’t cure your depression / anxiety if you aren’t trying your very best to lead a life based on honourable work, forming meaningful social relationships, exercise and eating right

Life Isn’t Fair, But If You Don’t Get This Simple Point You’ll Always Be A Sucker

Life is very unfair.  As much as we all wish that the success we enjoy in life is a direct consequence of our well thought out actions and intentions, it probably isn’t.  If you were born poor in rural Bangladesh, could you still confidently say that your quality of life would be as good as it is now?

You’re not pretty enough, thin enough, tall enough, rich enough, you were born to poor parents, you went to a bad school, you were born in the wrong part of the country, you’re the wrong colour…This list of excuses is endless.  It’s undeniable that these characteristics and ones upbringing does indeed have a large impact on your life’s trajectory.

This post isn’t about “victimhood”.  Everyone is aware that you have to hustle to get ahead in life and that without hours of hard work, you simply won’t get anywhere.

This post also isn’t about being “stoic” and just accepting that you can work hard, toil away and yet still achieve very little in life.

This post is about how we can embrace the randomness and entropy that surrounds us every day and use it to our advantage.  In short, this post will teach you how to win at life.  But first, a few illustrations are necessary.

Estimated Time of Arrival

Google Maps has replaced my Sat Nav machine.  I don’t know when it happened, but it definitely beats using a stand alone machine.  I was particularly put off using stand alone Sat Navs ever since someone broke into my car to steal one!  The burglar probably sold it for £20 at the local pawn shop, but left me with a repair bill of £120 for my car.

A few days a week I make a 60 mile commute to my clinic to see patients and make sure everything is running properly.  Get in the car, put my phone in my phone holding thingy and set the destination; “Estimated time of arrival 10.30AM”, it says.

It seems that Google Maps and lots of other navigation apps try to figure out the “quickest route to destination”.  We’ve all probably had instances where we’ve put the navigation on in a familiar neighbourhood and have blindly followed its instructions, even though we just know that if we went our usual route we would have gotten to our destination quicker.

This minor gripe is merely annoying, but the worst kind of problem with Sat Navs is when we go on those longer journeys.  “Estimated time of arrival 10.30AM”, it says, but why is it that most of the time I get to my clinic a few minutes after the ETA?  The worst is when something unforeseen happens, such as an accident on the motorway and I end up at my destination an hour or more late!

Why is it that I never get to my destination an hour or more early?

In England we have roads called “M” roads, which are the largest roads with the highest speed limits.  We then have other major types of roads such as “A” roads and “B” roads.  As you can imagine “A” roads are the next quickest after “M” roads.  Interestingly enough, Sat Nav systems always tend to pick routes with “M” roads whenever possible.

This is an interesting way to get to your destination.  “M” roads are definitely faster, but if there is an accident, then you’re doomed to suffer hours stuck in traffic wondering why that annoying Audi behind you is driving so close when there’s clearly a traffic jam ahead.

“A” roads on the other hand have plenty of tributary roads.  Traffic jam?  No problem, just turn off and join another road and you’ll be on our way with a merely slight delay.

Satellite navigation systems are missing out on a trick in my opinion.  Instead of being able to pick the “fastest route” it should actually give you two options;  “Fastest route, but if something happens on the road you’ll be REALLY late” or “Slower route, but you don’t need to worry about being too late if something goes wrong.”

I wonder how many people would choose the slower route with less variability when it comes to important journeys such as getting to the airport on time to catch a flight?

The Doctor-Patient Relationship

When I used to work as an acute general surgical doctor, we used to quip that it would be more cost effective to carry out a whole body CT scan as patients were carted on to the ward.  Almost, like those body scans at the airport!  It certainly would have made our lives as doctors much easier if we could simply just get the scan done and see whether there was something worrying to operate on straight away, instead of having to sit down with the patient and get their history.

The acute surgical ward was a stressful place to work.  Patients got referred in by the Emergency Department or Community Doctors and then we had to assess the patients and figure out if they needed an emergency operation.

The problem on this ward was that it meant you would have to spend at least 30-40 minutes with the patient, listening to their story, taking blood tests and then you’d have to wait for several hours for the blood tests to come back.  Once the blood tests were back, unless it was an obvious appendicitis or cholecystitis, you would have to organise a CT scan.  If you consider that many patients end up staying in the hospital overnight at a cost of £400, only to be told the following morning that all the investigations were normal and that they can go home, then having a CT scanner placed at the door doesn’t sound like a bad idea as a scan costs around £100 per patient.

You might be thinking that all these tests sound totally unnecessary.  I would agree with you.  The problem in medicine is that when a patient gets referred to you by another doctor, the onus falls on the accepting physician to ensure that nothing is wrong.  In other words the buck stops with you.

What do physicians with this onus do?  Test, test, test!  Do all the blood tests under the sun.  Does this patient actually sound like she has a simple urinary tract infection which can be treated with three days of oral antibiotics?  Doesn’t matter!  We can’t risk it!  We must do all the blood tests which will make sure her bowels, kidneys, liver, pancreas, anaemia levels are all normal and if these all come back normal then she must have a scan of her abdomen as well (exposing her to more than 500 times the radiation of a chest x-ray) to just be safe.

How did medicine get this way?  There seemed to have been a simpler time in medicine, which I personally didn’t get to experience.  My father on the other hand reminisces about those times frequently.  “There used to be a time where doctors were respected and decisions were made mutually with the patient”.  I, unfortunately have been trained and continue to practice medicine in an era of litigation and suspicion.

The threat of litigation and the risk of potentially losing your medical licence with every patient you see causes you to practice medicine a lot more “defensively”.  Even if doing more is potentially harmful, it is often better to be seen to do something (which is defensible in court) than not carrying out an intervention (which is indefensible).  “We might as well as take out that gentleman’s appendix, just in case.”.  If you don’t take out the appendix and then it does turn out to be an appendicitis, then set aside a date for court my friend.

Is This a Good Idea??!!

“Is this a good idea”.  Every budding entrepreneur mutters those words.  Usually, so often that it drives loved ones near to the edge of sanity.

When they ask “is this a good idea?”, what thy are really asking is “will I make tons of money from this?!”.  Many entrepreneurs say ideas don’t mean a thing, but that the execution of the idea is the main thing.  I agree with this sentiment….to a certain extent.  If the person I’m talking to isn’t an action taker, then for definite it doesn’t matter what idea he has, because they’ll never do anything.  Ideas by themselves are meaningless.  But, if I’m talking to a really smart person, who consistently takes action, then yes ideas do matter.

The number of businesses is growing every year.  What’s interesting is how few are successful and how little money most businesses make.  I mean they’re all businesses after all and a lot of them do pretty much the same thing, but why is there such a large difference in revenue between them?

Why is Starbucks so profitable while that small cafe ran by that pleasant family down the road is struggling to make ends meet?

Or better yet, why will that coffee store never become the next Google?  Now obviously, Google are providing a completely different service, but what are the factors that set apart your average family run coffee store to an Internet company based in San Francisco?

The anatomy of a good idea goes a long way to explain whether an idea is worth pursuing or not.

The World Is More Random Than You Realise

The world is a very random place.  We as human beings are predisposed to create narratives to help us make sense of the world.  It gives us the feeling that we can predict the future.  Daniel Kahneman, the Nobel Prize winner, has written about how our brains are wired this way.

I remember when I was in high school and my music teacher played a piece of music to me.  It was a recording of a flute playing random notes, in a random order, with no time signature.  What was interesting about listening to this totally random barrage of notes was how my brain couldn’t help but construct melodies out of thin air.  It was the musical equivalent of “don’t think of a purple elephant!”.  Your mind will construct thoughts automatically and come to conclusions as a reflex.

Apart from my own anecdotes, there have been many studies which have proved how truly random the world is and how poor, we as humans are at predicting outcomes and making decisions.

Philip Tetlock, from the University of Pennsylvania made a landmark study: “Expert Political Judgement: How Good Is It?  Can We Know?”.  In this study he asked 284 political experts to make 80,000 predictions.  In the study he gave the political experts a topic to consider and then gave them three options to choose from.  He later looked at if the predictions were correct.

The experts turned out to be worse than random.  Meaning that if he had gotten a monkey to randomly pick an answer, the predictions would have been more accurate.  One of the reasons that expert predictors get it wrong so often seems to be a result of knowing too much.  Experts seem to over complicate their predictions by looking at too many factors and making too many outlandish correlations.

For business owners / CEO’s and entrepreneurs, the news isn’t too great either.  I love entrepreneur books and biographies of successful people.  But they do for the most part seem more like fairy tales, rather than scientific studies of success.  Which is fine if you’re into that sort of thing.  However, studies have shown that the strength of a CEO and the success of the company that they are running are not well correlated at all.

If CEO’s were really the rock stars they are made out to be in the popular press then there should be a direct correlation between the success of their companies and their skill level.  If you took a really bad CEO running a company in a certain industry and then took a really good CEO running a company in the same industry, you should expect to find that the better CEO’s company is always outperforming the one ran by the worse CEO.  But the correlation hardly exists!  If the correlation was perfect (i.e. a good CEO always producing the best outcomes and beating the competition) then the correlation coefficient would be 1.  In reality, the best estimates place the coefficient at around 0.3, which is only very slightly better than random!

My point is that skill and knowledge clearly exist, but the world is an incredibly random place.  Most people’s ability to make decisions affecting their future are random at best and worse than average at worst.

How To Not Be A Sucker

What do motorways, being an acute surgical doctor and good business ideas have in common?  One word: asymmetry.

Asymmetry means that there is an unequal relationship present.  To compound this, as the world is so random and unpredictable, you never know when the asymmetry is going to hit you and how much of an impact it will have in your life.

Motorways for example have an asymmetry in terms of getting to your destination on time.  Either you’ll be a little early, on time or if something goes wrong on the roads, such as an accident, then you’ll be extremely late i.e. an asymmetry is present here.

In the world of medicine / surgery, there is an asymmetrical relationship between the physician and the patient.  Theoretically if a doctor makes a mistake with any patient they ever see, they can lose their medical licence.  Patients may genuinely come to harm in some cases, however in the UK, the GMC (General Medical Council) have stated that over 90% patient of complaints / litigation made by patients is unwarranted and unfounded.  There is an asymmetry in the relationship as patients can make a complaint which may be false, but there are no repercussions if their complaint is found to be based on a lie.  Patients do not get any financial repercussions or penalties if their complaint doesn’t get upheld.

These asymmetries exist in a lot of different domains in life.  For whatever reason most people are blind to this and are unaware of such relationships.  But if you are aware of these relationships it will cause you to make better decisions.

The two examples we’ve talked about above are what I call negative asymmetries.  Meaning that if a random even occurs then it will make your life worse.  But, you can also use asymmetries to your advantage!

Take for example business ideas.  Good business ideas have asymmetries present which could result in exponential / unlimited financial returns.  Most business owners simply aren’t aware of these principles.  This is the reason why that small coffee store down your road will always continue to struggle and why that pleasant family will never be financially free – even though they could be.

I could speak a lot about great business ideas, but the two main principles in good business ideas are the ability to scale and detach your own time from your business.

Say that you open a coffee store.  Part of your business mission should be to put systems and protocols in place so that every cup of coffee is produced in the same way at the same standard, the store should always be cleaned in the same way up to a certain standard, the way items are procured and how much they should cost should be standardised, the way customers are greeted and treated should be standardised.

Basically every aspect of the business should be run with protocols in place.  This way, if you, the business owner decide to leave for a couple of months for a holiday, your business will keep on chugging along as usual.  In other words, you’ve created a system which is not attached to your time or presence – you’ve just created a money printing machine, which is exactly what businesses are meant to be.

If you can detach your time from your business, then inevitably you have created a business model that is scalable.  There is no reason why you can’t open up another coffee store usinng the exact same training protocols you have already created in your first store to expand your empire.

Business success is random as we have already demonstrated.  But, if you have a well thought out business which can be scaled then randomness can have a positive impact on your business and life.  As businesses which are designed to scale have asymmetrical returns then you could win big and be financially free.

In life if you don’t set yourself up to win and use randomness to your advantage, then you will always be at the mercy of randomness and asymetries.  You will always lose and be a sucker.

Being A Doctor, What It Means, What It Doesn’t Mean, What It Will Mean

I.

I’d say that one of the main things that made me choose to become a doctor was that I felt like I had a kind of natural ability and affinity for the subject.  It’s likely that this was a completely false assumption however.  It stemmed from growing up in a highly medical background, where a lot of family and friends were involved in the field.  As a result I easily identified with the profession.  I assumed and it was presumed by many others that I would become a doctor as if it was somehow in my DNA (at this point it’s hard to say what came first.  My desire to become a doctor or the fact that everyone around me was saying that I would become a doctor.  A kind of chicken and egg scenario).

I recall when I was being taught Biology in Primary School for example and the other kids looking expectantly, as if somehow I already knew all the answers.  This continued on throughout high school.  There was one time when we were briefly being taught about electrocardiograms and for some reason the other people in the class and also the teacher started to ask me questions about how to interpret them.  This low-level reinforcement over many years is likely to have shaped my opinion on medicine and my own identity as a doctor.

When I began medical school it was really just a continuation of school.  The only thing that seemed to change from school was the fact that on top of going to a building to learn some random stuff everyday, when I got home my bed hadn’t been made and I had no food to eat.  The first three years did not involve seeing patients at all.  The theory went that medical students should have a baseline knowledge of this thing called “medicine” before we were even allowed to see an actual patient.  At this point in medical school if one of the medical students had seen a patient, it was almost like a yeti sighting.  “You saw a patient?”  “Where did you see this patient?” “Well, I kind of saw the patient as he was running off into the woods”.

I remember having conversations with my family out of sheer frustration.  Why do I have to learn all this random stuff before I can even see a patient?  I just want to be a doctor!  Why do I have to learn all this stuff which will never be needed?  My parents and my elder brother would reassure me from time to time.  The most logical answer they were able to provide was something along the lines of earning your stripes, or that it would all add up to making a good doctor or something like that.

Just to give you an idea, here is a (shortened) list of subjects which we had to study before we could even see a patient.  All of these had an exam at the end of the course, or you wouldn’t be allowed to progress further in the course:

  • Anatomy
  • Histology
  • Nursing
  • Human Studies
  • Biophysics
  • Biochemistry
  • Embryology
  • Developmental Biology
  • Physiology
  • Pathology
  • Pathophysiology
  • Ethics
  • Latin
  • Heath Information Technology
  • Forensics
  • Medical Biology
  • Microbiology
  • Immunology

There’s eighteen subjects in the above list.  So that’s at least eighteen major exams we had to pass to finally move on to clinical medicine and see patients.

Clearly, going to medical school was not what I had expected it to be.  However, even though I was really frustrated in those first few years in terms of not being able to see patients, I’d be lying if I didn’t kind of enjoy learning such a vast array of interesting subjects.  And because it was just like school again i.e. memorising a large amount of random stuff, I was doing quite well at the work.

Continue reading “Being A Doctor, What It Means, What It Doesn’t Mean, What It Will Mean”

Consultation Skills – Three Golden Rules

My consultation skills are gradually improving.  I’m currently seeing a patient every 10-12.5 minutes.  By the time I finish my training next August I need to be consistently at 10 minutes per consultation.

A couple of years ago when I started my GP training I really had no clue how GPs could see patients so quickly.  In the hospital doctors get more like 30-40 minutes to clerk a patient when they arrive to the ward.

I’ve found a few tricks that are really helpful for any budding GPs out there.  It’s also very handy for hospital doctors to know this stuff as well.  GPs have a very patient-centric approach in the way that they provide care.  Most patients genuinely appreciate this approach as it takes into consideration the patients social issues, their health beliefs and ultimately treats them like a human being.  I have often heard hospital doctors get into confrontations with patients because they have not taken a patient centred approach.  A lot of altercations could be avoided if more doctors would take the rules below into account.

So here are the three golden rules to get a super quick focused history: Continue reading “Consultation Skills – Three Golden Rules”