GUEST POST from Arlen Meyers

A recent report from Merritt Hawkins indicated that the average employed physician generates over $1.5M to their employer. Also, while there is a lot of noise about value based and bundled payment, the reality in the examining room is  “the healthcare environment remains solidly rooted in fee-for-service and other forms of volume-based reimbursement. According to a recent Health Affairs study, 94.7% of physician office visits were covered under fee-for-service arrangements, and just 5.3% under capitation payments.”In other words, docs have one foot in the boat and another on the dock.

In addition, entrepreneurs are creating new care delivery models, like urgent care clinics, new forms of primary care practices and retail based clinics and they are looking for ways to attract and compensate docs, particularly primary care docs, in ways that are both motivating and legal and not run afoul of Stark Laws.

Health systems leaders are trying to figure out how to manage clinical staffing and variation.As noted,  it is essential to address how the health system manages its clinicians, particularly physicians. This has been an area of explosive cost growth in the past 15 years as the number of physicians employed by hospitals has nearly doubled. In addition to paying physicians the salaries stipulated in their contracts, hospitals have been augmenting their compensation (e.g., by paying them extra for part-time administrative work and being on call after hours and by giving them dividends from joint ventures in areas such as imaging and outpatient surgery where the hospital bears most of the risk).

There is nothing simple about physician employment agreements when multiple federal agencies are watching over them. Here are 10 legal and regulatory landmines.

Furthermore, those doctors that generate the most don’t necessarily get paid the most, given that some specialists generate lots of downstream revenue in the form or tests, imaging studies and procedures, while other specialists generate less. In some instances, doctors generate almost 20x their salaries.

What to do with the doctor cash cows will continue to trouble sick care CFOs for the forseeable future. Revenue sharing, ESOPS ,delayed compensation and other forms of incentives, because of the nature of sickcare, rules and regulations or stock options will probably not be viable options.

Here are 10 reasons why it is so hard to kill fee for service (FFS) medicine:

1. Too many people make too much money doing it that way.
2. Politicians are afraid of enacting too much change too soon.
3. Entire industries, like EMR, CPT coding, and others have been built around optimizing the fee for service model.
4. Some would claim it would be like other “socialist” countries with more government power.
5. Many are wary of how the payment negotiations would play out and the end result.
6. Some want to get rid of third-party payment altogether and this is just making a bad system worse.
7. Many think “value” is a smoke screen and a ploy to pay providers less.
8. Pay for performance is not working.
9. Some stress that patients should decide what they want and how much they should pay for it and not be forced into a “panel” of patients.
10. There’s a presidential election campaign going on.

As we change more from sick care to health care and we see a gradual, real transition to bundled payments via MACRA, there will also be a MOO-vement to do something with the doctor cash cows.

 
Image Credit: Pixabay

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GUEST POST from Arlen Meyers

Knowledge technicians differ from physician managers who are different from physician leaders. In addition, not all physician leaders are entrepreneurs and few physician entrepreneurs are innovators.

The ” change impact funnel” looks something like this:

It starts at the top with a wide base of physician knowledge technicians. Most doctors are trained to do three things and to do them well: make decisions, perform technical procedures and communicate. In other words, they are expected to be a first class diagnostician and technician and have a pleasing bedside manner. Few are triple threats and many of these skills are being replaced or supplemented by deep learning, AI and robotic technologies. Consequently, we have redefined what it means to be a triple threat.

The second level of impact is the physician manager, someone who is expected to optimize the efficiency and effectiveness of business, marketing and clinical policies, procedures and processes. They are agents of the existing clinical care and business models. Their entire focus is on the now and not the new. They do the thing right, not necessarily the right thing.

Physician leaders occupy the next level and are expected to provide vision, direction and inspiration and drive the change process. Some see their role as incremental tweekers, leading the painful and difficult process of changing the existing model. Others see their role as making the model obsolete. They typically try to follow John Kotter’s 8 step change paradigm: unfreeze by creating a sense of urgency, changing behavior, and then refreezing the new behaviors to engraft them on to the culture and make them sustainable.

Physician entrepreneurs take it one step further, taking advantage of opportunity with scarce, uncontrolled resources with the goal of creating user defined value through the deployment of biomedical and clinical innovation. Often times, their outcomes will be in conflict with physician managers who are there to protect, not disrupt, the status quo, or leaders who don’t have the same vision.

Some physican entrepreneurs are innovators, occupying a space in the upper right hand corner of the novelty-value matrix

Where you sit on the matrix is dependent on how much time you are spending on the now (lower left), the next (right lower) or the new (upper right quadrant). The upper left quadrant is the place in hell reserved for shiny new objects at the apex of the hype cycle that create little or no user defined value at significant multiples when compared to the competition or the status quo.

Finally, there is that rare combination of physician innovator who leads and inspires other physician innovators, the leaderpreneur. They are hard to find, highly valued and difficult to retain.

Here is a recent list of healthcare entrepreneurs recognized by their peers. Some are physician entrepreneurs who span the change impact funnel. It remains to be seen whether they will make the cut next year.

Beatrice was Dante’s muse in the Inferno. Fortunately, we are seeing more and more physicians serve as role models for others who want to navigate the innovation inferno.

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GUEST POST from Arlen Meyers

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GUEST POST from Arlen Meyers

Water and steam powered the first industrial revolution. Think water powered mills and the steam engine. Cyberintelligence is driving the fourth. However, many are qestioning the wisdom of so much emphasis on STEM (science, technology, engineering and math) to the exclusion of other disciplines that supposedly promise to get us to the promised land of equitable prosperity.

It’s time to recreate STEAM (social sciences, technology, english, arts and media) and here are the reasons why:

1. The most creative innovations of the digital age came from those who were able to connect the arts and sciences.
2. Technology industries, like most industries, cannot be fixed from inside. The next phase of the digital revolution will bring a true fusion of technology with the creative industries, such as media, fashion, music, entertainment, education, literature and the arts.
3. Artists are better at seeing around corners and separating the signal from the noise
4. Two key components of the innovator’s DNA are observing and associating
5. We need better story tellers, particularly those that know how to do it using cutting edge information and communications technologies
6. Customers buy emotionally and justify rationally. We need entrepreneurs who know how to appeal to the heart and soul, not the head, or hire someone who does
7. New ideas come from the collision of disparate industries at the edge
8. Mindset, creativity and imagination are the foundation of innovation
9. Stories matter. What people tell each other can have profound implications on markets — and the overall economy.
10. It is a myth that new STEAMers make less money or are unhappier than techies, engineers, or scientists. Just ask your molecular biologist daughter -in-law who is doing her 3rd postdoc. The MFA is the new MBA.

Here is how and what we need to teach students to win the 4th industrial revolution. We need to reinvent the STEAM economic engine.

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GUEST POST from Arlen Meyers

The purpose of doing the problem-solution, value proposition design exercise is to find the customer segment and identify the jobs they want you to do, the pains they are experiencing now doing it, and the expected gains they want from your product or service. Clayton Christensen described the “jobs to be done” credo in his lastest book, Competing Against Luck.

For example. here are the jobs to be done for college students.

One error is to focus exclusively on the technical job e.g. create a drug or device that treats or cures an illness or helps a surgeon do the job. But, in sick care, there are many other jobs customers, influencers, decision makers, payers,end users and sabateurs want you to do, or in the latter case, don’t want you to do. In addition to technical jobs there are:

1)Emotional jobs

2) Social jobs

3) Business model jobs

4.) Workflow simplification jobs

5) Regulatory approval jobs

6) Reimbursement and revenue jobs

7) Cost cutting jobs

8) Patient and doctor experience jobs

9) Compliance jobs

10) Time saving jobs

11) Service jobs

12) Convenience jobs

For the most part, doctors want you to create a QWILT SET. Patients value other things and want you to focus on different jobs, like making care affordable and convenient. The result are value gaps for different stakeholders.

Finding the right problem-solution fit, product-market fit and business model-environment fit are 3 key steps to creating products and services customers are willing to use and buy using a viable business model. Don’t stop at creating an app that takes your temperature and sends it your daughter in Cleveland.

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GUEST POST from Arlen Meyers

There are presently 141 accredited MD-granting institutions and 31 accredited DO-granting institutions in the United States. Here is a list of the programs that offer MD/MBAs. The list seems to be growing each year.

Like management MBAs and law degrees, the degrees have become commoditized and lack any real differentiation. Some argue the same holds true for medical degrees.

Applications to some of America’s most elite business schools fell at a steeper rate this year, as universities struggled to attract international students amid changes to immigration policies and political tensions between the U.S. and China.

There are other problems as well.

1. We don’t know how much value the graduates contribute to the sick care system.

2. The programs are usually not domain specific. Some think that’s a good thing, encouraging exposure to how other industries have solved generic problems Others feel sick care is so unique, that the lessons are not applicable.

3. Medical students are already up their waists in debt, most of which is taxpayer subsidized. Should additional debt be added to their student loans ?

4. Few of the programs address the needs of physician entrepreneurs.

5 There are many substitutes for physician entrepreneurs around the world and US schools are no longer the mecca.

6. Content has become generic and offered for free on the Internet.

7. Connections are easily to make using social media.

8. The MBA is losing credibility, given the large number of places that offer them, particularly those below the first tier schools.

9. Employers can see through the credentials

10. Costs continue to escalate and the programs do not accomodate the specific needs of busy clinician students.

Rather, if the purpose of graduate business and management education is to educate and train medical students to create value in the sick care system, we should be thinking differently by:

1. Offering MBEs not MBAs
2. Create entrepreneurial medical schools
3. Track and monitor MD/MBA outcomes
4. Rethink providing student loans to cover graduate business education
5. Require more work experience from medical graduates before admission.
6. Stop using the programs as cash cows for business schools who are feeding the needs of doctors who want to get off the clinical track rat race for an administrative job and be a “sick care influencer”
7. Do a better job of integrating STEM schools with business schools with arts and sciences during undergraduate and graduate education
8. Define medical practice entrepreneurship competencies as part of ACGME accreditation of residency training programs
9. Rewarding faculty with promotion and tenure credit for the scholarship of innovation
10. Stop deceiving ourselves that innovative medical schools are entrepreneurial medical schools

The MD/MBA bubble has burst and the degree no longer has legitimacy. They provide expensive connections, credentials, credibility and content, in that order of perceived worth. We need to redefine our learning objectives and create educational programs with a structure, content and price that meets market needs. We need to kill the MD/MBA cash cow recognizing that vested interests won’t sit idly by while we do it.

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GUEST POST from Arlen Meyers

Enormous amounts of patient data creates big business opportunities. In fact, some day, patient sick care might be a loss leader. Instead, the revenue model will be patients owning data and using a platform to sell it for a price. Patients will become digital health entrepreneurs.

Selling your sick care data is called an “edge opportunity”.

We are headed in that direction.

1. Blockchain technology could make it easier for patients to own their data and share it , or sell it, with anyone they choose
2. Third party data science companies will churn submissions and deliver information and actionable intelligence as a service
3. The FDA will change how it regulates software as a device, data as a service and intelligence as a service
4. Online platforms will broker the two sided market between the buyers and patient sellers of data
5. ICOs will cater to data sellers in exchange for cryptocurrencies
6. Public databases that are open to data and biomedical scientists will be open for research, much like present genomics data bases run by public agencies like the NIH and NCI
7. Data entrepreneurs will translate publically available databases to commercial products
8. Data selling and the resulting revenue will be a new employee benefit for those working for self insured corporations, unions or other entities. Patient reported outcomes will one of the data sources along with the internet of medical things.
9. Value based care intermediaries will create a new revenue model
10. The sick care data value chain will evolve and get more complicated. It will start with patient owned data and eventually be bought and sold though a series of value added steps by intermediaries. Here is what it looks like:

• Discover: In today’s digitized world, there are many sources of data that help solve business problems that are both internal and external to organizations. Data sources need to be located and evaluated for cost, coverage, and quality.
• Ingest: The ingest pipeline is fundamental to enabling the reliable operation of entire data platforms. There are diverse file formats and network connections to consider, as well as considerations around frequency and volume.
• Process: Many applications are well served by processing data immediately following the ingest stage, to transform the data into a format that facilitates its reuse or to take immediate action based on incoming events.
• Persist: Cost-effective distributed storage offers many options for persisting data. The choice of format or database technology is often influenced by the nature of other stages in the value chain, especially analysis.
• Integrate: Much of the value in big data can be found from combining a variety of data sources to find new insights. Integration is a nontrivial but valuable step in which this combination process occurs.
• Analyze: The star of the big data show—analysis—depends critically on every other step in the value chain—the so-called data janitorial work that makes up 80 percent of data science. New insights and actions are derived from data, enabled by an ever-growing and nuanced choice of tools and platforms.
• Expose: The results of analytics and data that are exposed to the organization in a way that makes them useful for value creation represents the final step in deriving value from data.

11. We will need to address the societal and ethical implications. Who rules AI? There are three basic challenges: data protection requirements, minimizing biases and transparency.

12. Silicon Valley startup Open Health Network, which develops AI-based applications for healthcare organizations like UCSF, Sanofi and Cornell University has launched a new product meant to use blockchain technology to allow patients to manage and monetize their medical data. If successful patients will be able to sell their assets on the PDX. a NASDAQ for patient data.

Of course, there will be a dark side to all of this. Every time shoppers return purchases to Best Buy Co. , they are tracked by a company which has the power to override the store’s touted policy and refuse to refund their money.

That is because the electronics giant is one of several chains that have hired a service called The Retail Equation to score customers’ shopping behavior and impose limits on the amount of merchandise they can return.

Will patients be refused services for “abusing” the system, or doctors refused payment because they take care of them? Aetna already tried that, but had to back off after the backlash.

Airlines might charge you based on your online shopping history. Will the same thing happen to your sick care insurance premiums?

Nearly one in five employees in the healthcare field said they’re willing to sell confidential data like login credentials to unauthorized parties, a new survey from Accenture claims. Nearly one quarter of the survey’s respondents said they know someone in their organization who has sold their credentials or access to an unauthorized outsider.

A bid and asked sick care data revenue model is inevitable.What would you charge for your data ? What’s in your iPhone?

 
Image Credit: Pixabay

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GUEST POST from Arlen Meyers

I’m a privileged, old white guy who won the ovary lottery. My child of immigrant, first generation to college father got advanced degrees. Consequently, I was able to grow up in the right ZIP code and take advantage of the opportunities afforded to me by sheer dumb luck. As a result, I wound up being an academic surgeon and worked at the same place for 40 years until I retired as an emeritus professor to pursue my next encore side gig, including working with several non-profits that sit at the intersection of sick care, higher education, biomedical and clinical entrepreneurship and diversity, equity and inclusion.

Like everyone else though, regardless of status, there was a lot of life collateral damage along the way.

Increasingly, my story has become a rare one. A more common commentary is getting multiple degrees with big student debt, jumping from job, or side gig or career to job or side gig or career, no retirement savings and living in your parent’s house. Just ask your Lyft driver who’s moving back in with mom and dad. Younger people are also more likely to be lonely.

Members of Generation Z, born between the mid-1990s and the early 2000s, had an overall loneliness score of 48.3. Millennials, just a little bit older, scored 45.3. By comparison, baby boomers scored 42.4. The Greatest Generation, people ages 72 and above, had a score of 38.6 on the loneliness scale.

I pursued these adjacent careers because, in part, after 40 years of taking care of 20 patients a day, I increasingly felt I was treating the societal and systemic symptoms and not the disease. They are wicked problems indeed with no simple single bullets.

The disease- opportunity, income,healthcare and education inequality- has become epidemic and all the statistics show it.

As one of the haves, I’m trying to set an example for the other haves and show why and how diversity, entrepreneurship and sick care are wicked problems requiring inter-system solutions and why it is in the best interests of old white guys like me to solve them.

Here’s are 3 reasons:

THERE ARE COMPELLING BUSINESS REASONS TO DO IT

Four key arguments make the case for diversity, equity, and inclusion:

• The moral or social justice case asserts that each person has value to contribute, and that we must address barriers and historical factors that have led to unfair conditions for marginalized populations. For example, racial equity refers to what a genuinely non-racist society would look like, where the distribution of society’s benefits and burdens would not be skewed by race, and individuals would be no more or less likely to experience them due to the color of their skin. From a moral perspective, nonprofits are created to improve society and as such they should be diverse, inclusive, and equitable.
• The economic case is based on the idea that organizations and countries that tap into diverse talent pools are stronger and more efficient. Economists see discrimination as economic inefficiency – the result of a systematic misallocation of human resources. In fact, the Center For American Progress finds that workplace discrimination against employees based on race, gender or sexual orientation costs businesses an estimated $64 billion annually. That amount represents the annual estimated cost of losing and replacing more than 2 million American workers who leave their jobs each year due to unfairness and discrimination. In this argument, organizations should become more diverse and inclusive because it makes economic sense to leverage the talent pools of different populations.
• The market case states that organizations will better serve their customers if they reflect the diversity of their market base. A dramatic demographic shift is under way in the U.S., which will be majority non-white around 2043 according to the Census Bureau. In the private sector, companies such as Deloitte recognize the buying power of minority populations and highlight that diversity is critical to growing market share and bottom line. In the nonprofit sector, clients are our customers, and they want to see themselves represented in the organizations that serve them. Donors are also customers, and organizations and their clients can benefit from the resources of different groups. What’s more, organizations with diverse leadership are more likely to understand the needs of a diverse client base.
• The results case is that diverse teams lead to better outputs. Scott Page, author of The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools and Societies, uses mathematical modeling and case studies to show how diversity leads to increased productivity. His research found that diverse groups of problem solvers outperform the groups of the best individuals at solving problems. Diverse nonprofit organizations, and the diversity of perspectives within them, will lead to better solutions to social problems.

SICK CARE CANNOT BE TRANSFORMED INTO HEALTHCARE WITHOUT ADDRESSING THE SOCIAL DETERMINANTS OF ADVERSE OUTCOMES

I’ve worked for many years in “safety net” hospitals-city and county hospitals, university hospitals that take care of a disproportionate share of poor patients, VA patients who are homeless, and native American facilities located on reservations with a culture of poverty. In most instances, health success has little of nothing to do with what goes on in the examining room. Instead, the psycho-social and behavioral health context usually is a predictor of treatment success or failure. In most instances, doctors are ill-prepared to deal with those issues and live at the epicenter of medicine, the legal system, medical sociology and a very dysfunctional mental and behavioral health pseudo-system.

UNHEALTHY STUDENTS MAKE POOR LEARNERS

Here is how education affects health and the price we, as a society, are paying by ignoring the long term consequences.

Most diversity and inclusion conferences are filled with the faces of a demographic that does not reflect the faces back at the office. Most of the people in the corner offices , like in IT, financial services, law and medicine, are older white guys like me.

While demographic diversity is important, psychographic diversity is equally important when it comes to creating high performance teams.

Plus, Pew asked a nationally representative sample of white men with jobs in science, technology, math and engineering (or STEM) fields whether they thought their gender made it harder for them to succeed. Of the 14 percent who said yes, more than one in 10 said they had been affected by reverse discrimination.

Women in medicine burn out more than men. Solutions will need to address personal, professional cultural, organizational and systemic issues.

The agenda for change should be at multiple levels:

1. Personal to build resilience and action plan to confront examples of sexism, e.g. not participating in manels that are not diverse, academic glass ceilings, board representation, etc

2. Organizational to remove sexism and stereotypes through transparent policies and procedures and outcome metrics and future of work issues (job sharing, gig economy, changes in the structure of pensions and benefits, etc)

3. Medical professional cultural to recognize the differences in female physician practice styles and unique accomodations that need to be made for family and child care giving and maternity issues. particularly in medical specialties like general surgery, orthopedics and others that have female under representation.

https://www.ama-assn.org/residents-students/specialty-profiles/these-medical-specialties-have-biggest-gender-imbalances

4. Systemic to remove administrivia and non-essential care giving tasks and reimbursement rules that discriminate against specialties with high female participation

Changing that will mean those with the power will have to give it up in order to get more power. As a recent diversity and inclusion keynoter noted, be a go giver, not a go getter. Be the solution, not the problem.

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GUEST POST from Arlen Meyers

In their book, The Innovator’s DNA, the authors identified 5 parts to the secret sauce of innovative business success:

In thinking about how these skills work together, they found it useful to apply the metaphor of DNA. Associating is like the backbone structure of DNA’s double helix; four patterns of action (questioning, observing, experimenting, and networking) wind around this backbone, helping to cultivate new insights. And just as each person’s physical DNA is unique, each individual we studied had a unique innovator’s DNA for generating breakthrough business ideas.

Innovation starts with mindset. Most scientists, engineers and health professionals don’t have it. However, there are ways to develop and change the gene expression by practicing epigenetic exercises. In case you missed that biology class, epigenetics literally means “above” or “on top of” genetics. It refers to external modifications to DNA that turn genes “on” or “off.” These modifications do not change the DNA sequence, but instead, they affect how cells “read” genes.

So, if you want to unlock your innerpreneurial genes, try :

1. Associating, by realizing that sickcare USA cannot be fixed from inside.
2. Associating by practicing open innovation
3. Associating by thinking twice about thinking out of the box
4. Questioning by being a problem seeker, not a problem solver
5. Questioning why not instead of why and getting to why
6. Observing by learning to see around corners
7. Observing by looking for the clues, not the roadmap
8. Experimenting by using the business model canvas instead of writing a business plan
9. Experimenting by applying your clinical or scientific mindset
10. Networking by building robust internal and external networks
11. Networking the right way when coldLinking
12. Networking by learning how to meet up at a Meetup

Here are some more ways to sharpen your entrepreneurial skills.

Doctors have the potential to make great entrepreneurs because they have the DNA. No, they are not lousy business people. Downstream gene expression, though, is often a problem.

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GUEST POST from Arlen Meyers

Business plan. Those two words have been used a lot to kill a lot of innovative ideas. Yet, it persists in the entrepreneurial consciousness. It’s a mainstay in the manager’s tool box. Sure, it you are going to ask for money, you will in all likelihood need to write a business plan. But, so few entrepreneurs actually get to that stage, that it’s putting the cart before the horse. I’m not the only one who thinks so. There are lots of reasons why writing a business plan, or even worse, telling someone to write a business plan, is a bad idea. Here are some more:

1. Business plans are usually smoke and include financial projections that, at the most, are guesses without valid underlying assumptions on which they are based.

2. There is little evidence that business plans are related to business success.

3. Few successful businesses wind up doing what they said they would do in their initial business plan

4. Few investors or sponsors want to see a business plan first. They want a concise pitch that generates further interest.

5. As Guy Kawasaki points out in ” The Art of the Start: 2.0″, business plan competitions are really pitch competitions. It would be a whole lot easier for BP judges to watch submitted 3 minute videos than have to plow through pages of business plan submissions.

6. Business plans are used by dull managers to dissuade innovation. Have an idea that could kill our cash cow? Go write a business plan and get back to me. It’s called triage by inconvenience.

7. Most intrapreneurs don’t know how to write a business plan so it’s another way to kill ideas.

8. Planning is different from writing a business plan

9. Most of what you would put into a business plan anyway can be validated before and if you get to that stage.

10. Better to create and test a business model canvass than a business plan

Distracting you and hoping you’ll get discouraged is but one arrow the in the anti-innovative bureaucrats quiver. There are many more:

Deflection: turfing you to the death committee

Delay: Maybe some other time

Denial: We don’t have a problem

Discounting: It’s really not that big of an issue

Deception: They make up facts that discredit you

Dividing: Divide and conquer

Dulcifying or appeasing: Making meaningless concessions

Discrediting: Sniping

Destroying:Trying to ruin you and your reputation and get you to quit or retire

Dealing: Compromise and give you just enough to make you go away.

Maybe you work in a place with this org chart:

There are alternatives to writing a business plan based on :

Prototype: Sketch out your idea quickly with the Business Model Canvas and Value Proposition Canvas.

Question: Ask yourself what needs to be true for your idea to work, i.e. define the underlying hypotheses.

Test: Test the desirability (will customers want it?), feasibility (can I build it?), and viability (will it be profitable?)

Iterate: Adapt your initial rough Business Model and Value Proposition Canvas and refine with increasing evidence from testing.

Here are some more innovation killers

 Still not convinced? Try these too.

Look out for killer phrases that start with “That’s a good idea, but…”

1. It’s against company policy
2. It’s not practical
3. It’s not necessary
4. We don’t have the resources
5. It will cost too much
6. We’ve never done it that way
7. Our customers (or vendors) won’t like it
8. It needs more study
9. It’s not part of your job
10. Let’s make a survey first
11. Let’s sit on it for a while
12. That’s not our problem
13. The boss won’t go for it
14. The old timers won’t use it
15. It’s too hard to administer
16. Why hasn’t someone else suggested it before?
17. Let’s form a committee
18. We should wait until the economy improves
19. Who else has tried it?
20. Is it best practice?

More innovation killers are :

• Unconscious neglect: a tendency toward carelessness and impulsivity, such as sending work before it’s ready or rushing to send responses that come across as uncaring.
• Overprotectiveness: reserving your best work and being reluctant to share achievements for fear that your ideas will be stolen.
• Overconfidence: leaning on your ego and willpower rather than asking for help, even when you need it.
• Overexertion: pushing yourself beyond reasonable limits.
• Devaluation: taking success for granted and under-appreciating relationships and resources out of an urge to pursue “the next new thing.”

No business pllan survives the first customer, and it is definitely helpful to plan. However, writing it as the first step is another story and just discourages innovators. Stop it.

Maybe those two words will help.

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