Personalised medicine v. National debt

Another day, another expensive cancer treatment gets rejected on cost grounds.  This time it's the turn of Novartis' renal cancer drug Afinitor: -

Despite appeals from Novartis and Kidney Cancer UK against the National Institute for Health and Clinical Excellence's decision, the watchdog maintains that Afinitor (everolimus) simply does not provide enough benefit to justify its high cost...

The overall treatment cost (is) about £34,235 per patient per year, or around £205,000 for a full course of treatment.

Pharma Times Online, April 19

These stories are commonplace across the Western World and for the moment, they are seen as part of the everyday argy-bargy of Big Pharma's negotiations with the national governments that are their ultimate customers.

But note the complete alignment between the pharma company and Kidney Cancer UK, a patient advocacy group that most likely receives funding from Novartis.  As stated previously, I have no problem with pharma companies pushing the patient to the centre of the treatment discussion.  There are neither cloaks nor daggers here and Kidney Cancer UK would exist even without the support of the various purveyors of renal cancer therapies.

As cancer is a quasi-chronic condition (i.e. one you see coming and so fight on your own behalf), sufferers and their families tend to be highly motivated people with an automatic tendency towards political agitation.  Cancer is hitting the baby boomers hard and they're unlikely to accept the withholding of any therapies whatsoever.  They will place inordinate pressure on a health system, which often leads to politicians creating release mechanisms: -

If doctors feel that any of these individual patients would benefit from the drug then they can still apply for exceptional funding from their primary care trust or the Cancer Drugs Fund, the Institute noted.

Ibid

All of which is fine if you live in the UK (and have a doctor sufficiently motivated to fight the good fight on your behalf).

But what if you're a Greek, Portuguese or Irish national?  As sad as your story undoubtedly is, given its current financial predicament, can your government honestly justify spending €38,500 on one citizen when that amounts to a year's wages for a senior nurse?

Watch the Greek, Portuguese and (especially) Irish baby boomers heap increasing political pressure on their governments; directly via advocacy groups and indirectly by turning up in person at British, German and French cancer centres.  Then watch for renewed pressure on the cost of the drugs themselves.

Identifying the scarce resource

Most definitions of economics stick pretty close to that of Lionel Robbins: -

The science which studies human behavior as a relationship between ends and scarce means which have alternative uses

The debate over how to best allocate finite resources amongst infinite demands is a commonplace and nowhere more so than in in the health care arena.  We're all going to die of something so the expense of sickness will always outstrip funds available for cure.

Successful pharmaceutical marketing is the process of ensuring that the condition treated by your drug enjoys as high a priority as possible in the system in question; be it the WHO, the NHS, a Strategic Health Authority (SHA), a Hospital Trust or the patient cohort seen by the individual GP.  The truth is that resources (time, money, beds) given over to HIV is a potential denial of diabetes treatment.  HIV wins so diabetes loses.  Or vice versa.

At an intellectual level we generally accept that quasi-objective measures like the QALY (quality adjusted life year) are necessary yet they seem wholly callous when applied to the treatment of people we love.  Tabloid papers thrive on stories condemning the cruelty of the 'postcard lottery' which is just the shorthand for the situation whereby different parts of a country have different health priorities.  For example, it is far better to get cancer in the southeast of England than west Scotland because Glasgow's cardiovascular issues are (still) a higher priority than cancer.

Doctors are trained to react subjectively (i.e. in the best interest of the individual patient) which often puts them in opposition to the objective needs of the system (NHS, SHA, Trust).  Pharma selling exists in part to exploit this gap.  This is not unethical per se; the representative is trying to promote the interests of the patient whose health needs will be best met by her drug.  Win-win.

The scarce resource most important to the pharma company is not the drug budget (although this is of course vital), but rather the motivation of the individual doctor to fight for the individual patient / drug.  Every day almost every doctor in Britain is faced with the prospect of having to fight for access to a treatment for a particular patient.  Not every doctor takes up every patient's cause as it would be impossibly exhausting to do so.

Identifying which customer has the energy to take the fight to the system on your behalf is a vital task for any salesperson selling into a complex system, especially when that system uses inertia as a cost control mechanism.

ANZAC Day

“When the Rakuyo Maru went down with seven hundred Australians and six hundred British aboard, it was the Australians who tried to preserve the biggest prisoner tribe.  On the third day in the water, some Englishmen who were almost finished sighted a mass of black shapes.

As we drew nearer we saw there were about two to three hundred men gathered on a large pontoon of rafts.  They had erected a couple of lofty distress signals, coloured shorts and other bits of clothing fixed to spars of wood.  As we paddled up we saw there was a large outer ring of rafts linked to each other with pieces of rope.  Inside the circle were other rafts, unattached but safely harboured.  They seemed organised compared with the disintegrated rabble we had become during those last two days.  They may have been drifting aimlessly as we had; but at least they all drifted together.  A lot of them still wore those familiar slouch hats – we had caught up with the Aussie contingent.

One of them looped us in with a dangling end of rope.  ‘Cheers mate,’ came the friendly voice.  ‘This is no place to be on your lonesome’.”

British Account of the Sinking of the Japanese POW Ship Rakuyo Maru

2B or not 2 B2C

On Thursday I did what I suspect was one of my last ever stand-up gigs.  I'm not sure when the absolute last one will be but it's fair to say that I have many more gigs behind me than ahead.  It was a pleasant enough show run by an old comedy friend in a country pub.  My set went well but it's a long time since a gig felt like a portal to anywhere special and in the five years I've been learning this craft my life, especially my business life, has moved on.

This was crystalised for me by a throwaway line in a podcast about the 90's Dotcom boom.  The discussion centred on the two basic business models operating at that time:-

Business-to-Consumer (B2C) versus Business-to-Business (B2B)

A distinction that perfectly illustrates the divide between my comedy and my consulting.  It is the divide between Art and Commerce.  As much as I like to think I have something to say to other individuals (B2C, Art), I have twenty plus years evidence that what the cosmos wants to reward me for are my insights into how companies operate and how they could do so better (B2B, Commerce).

Set out in print it's obvious.  I am a journeyman comic who's happy to pick up a few quid for a twenty minute set in the back room of a pub in rural Wiltshire but I am also one of the highest paid consultants in my field with clients all over the globe.  My ability to make a few punters laugh on a Saturday night is passable whereas the effect I will have on your pharmaceutical sales/marketing operation is unsurpassed.

From an early age it seems as if we're programmed to aim first for Art.  My parents stumped up for lessons in music and drama and art.  They spend their weekends ferrying me and my sisters to performances on stage and sporting fields across rural NSW.  Yes, I know that a child's participation in sport or art is its own reward but buried in there somewhere in there was the message that if I had the talent then Art (including sport) was the direction my life should take.  How many conversations have we each endured with disillusioned friends and colleagues revealing that they were actually 'quite good' at some Art or other, lamenting the day they threw it over in favour of the financially secure embrace of Commerce?

Commerce is Plan B.

In generations past Art was something that you did on the side.  Few people could afford to give up their day jobs.  Nowadays new media's appetite for 'content' has led to rampant inflation in the earnings of our top sportsmen (but not sportswomen), actors, comics and the like.  Papers and magazines responded by overpaying snarky columnists to retain readers.  Needing something or someone evermore 'outrageous' to write about they in turn opened the door for the BritArt master branders like Tracey Emin and especially Damien Hirst to parlay scarcely deserved notoriety into massive financial windfalls.  For a chosen few Art now pays like never before.  The rest of us stand, necks craned, on the far side of the velvet rope.

I've suffered ferocious writers block with my comedy for almost two years.  It's gotten so bad that in the cause of generating interesting and unique material I've contemplated taking on some strange, arduous new experience like the Three Peaks challenge, the Alpha Course or fatherhood.  This is what middling comics do when they've extracted all available humour from their upbringing and neighbourhood.  Yet my experiences as a stand-up have helped take my consulting to another level.  Not only has my ability to command attention in a room been strengthened but my arduous experiences in comedy have also afforded any number of interesting and unique angles as a consultant.  Oh, the irony.

I am a quite exceptional marketing consultant and an entirely unexceptional stand-up comic.  My talents obviously lie in B2B.  Why is it so hard to admit this fact?  When I meet someone at a party why do I want to describe myself as a performer and writer rather than as 'a marketing consultant who helps drug companies sell their drugs better'?

What isn't to be just isn't to be.  I think I'm sufficiently free of self-delusion to know that I'm not just one more stand-up gig away from fame and fortune.  The fortune is more or less covered.  It's the fame I'm denied.

Will you know if you've failed the audition?

Whenever any of us takes a leap in life and doesn't meet with immediate gratification the cold, hard fact of failure being a possibility appears: -

What if, at the end of the day, it's not meant to be?

How will you even know? How will you ever know? How long will you give this adventure and what needs to happen to trigger your retreat to some safer place? Will you stop when the money runs out or will it take that someone who you know genuinely loves you to burst into tears and beg you to quit? Perhaps your idea of success is more relativistic; what about the day you open the paper and see that all those second-raters you started out with have made it where you were planning to go? That poses a different question: -

What if, at the end of the day, it's not meant to be me?

This is a harshly different proposition. It's bad enough for the idea that prompted the leap into the unknown to suck but so much worse if it's just you that failed the audition.

I don't know that I've got much positive to say about this scenario. There are those around you who love and care for you who will tell you to persist and others who will tell you with equally genuine love to give it away.

Why consultants aren't popular

I spent much of the week working with a team of experienced and largely successful salespeople.  As my job was to change them in some way they rightly resented me from the off.  Scott Adams, creator of Dilbert, said it best: -

People hate change and with good reason.  Change makes us stupider, relatively speaking.  Change adds new information to the universe; information that we don’t know.  Our knowledge – as a percentage of all the things that can be known – goes down a tick every time something changes.

And frankly, if we’re talking about a percentage of the total knowledge in the universe, most of us aren't that many basis points superior to our furniture to begin with.  I hate to wake up in the morning only to find that the intellectual gap between me and my credenza has narrowed.  That’s no way to start the day.

On the other hand, change is good for the people who are causing the change.  They understand the new information that is being added to the universe.  They grow smarter in comparison to the rest of us.  This is reason enough to sabotage their efforts.  I recommend sarcasm with a faint suggestion of threat.

The Dilbert Principle (1996)

The cliches imply that unless you 'embrace change' and 'face the fear' and 'seek out new experiences' and so on then you're some sort of loserish Luddite.  This is offensive towards anyone who aspires to be good enough at her job to get paid fairly so that she can channel her enthusiasms elsewhere.  Like raising a family.  As a friend of my father's used to say: -

You can't argue with decency

Every time I walk into a new room my first task is to overcome the natural, rightful resentment of the decent people whose behaviour I've been paid to change.

Seth Godin on failure

Seth Godin's site still throws up some decent insights from time to time...

Here are six random ideas that will help you fail better, more often and with an inevitably positive upside:

1. Whenever possible, take on specific projects
2. Make detailed promises about what success looks like and when it will occur
3. Engage others in your projects. If you fail, they should be involved and know that they will fail with you
4. Be really clear about what the true risks are. Ignore the vivid, unlikely and ultimately non-fatal risks that take so much of our focus away
5. Concentrate your energy and will on the elements of the project that you have influence on, ignore external events that you can't avoid or change 
6. When you fail (and you will) be clear about it, call it by name and outline specifically what you learned so you won't make the same mistake twice. People who blame others for failure will never be good at failing, because they've never done it

I especially like 3.  Involving others is the first necessary step away from self-employed solipsism.

When is a hobby not a hobby?

If in your heart-of-hearts you believe that your hobby is a potential portal to something else then it isn't a really hobby is it?  If you kinda-sorta think this thing you do on the side might one day make you wealthy enough or famous enough to supplant your 'real' job then you'd do well to treat it with the seriousness of an actual job.

Anything less and you'll always feel a little bit short-changed.

Why China is hard on trainers

I do some consultancy in China and like every businessperson in the Western world I'd like to do more. 

An interview in Bloomberg sets out one key reason why I won't hold my breath when it comes to a huge uptick in work in developing markets.  Abbas Hussain is GlaxoSmithKline's president of emerging markets on his teams in China and India: -

Every year, about 20 percent of GSK's sales force quits to take jobs at rival firms, Abbas Hussain says.  And that's about average for the pharma industry in those markets, meaning that most if not all drugmakers share the turnover problem

Even in good times this is a key difference between established and emerging markets.  In Europe, North America and Australia the most common reason given by a salesperson voluntarily leaving is 'Lack of development' whereas in China and India companies are in a straight-out bidding war.

My stuff certainly enhances a team's professional (and personal) development which is why I work mostly in stable pharma markets like Europe.  Unfortunately it's still hard for a Chinese COO to justify flying in a London-based consultant to deliver in Beijing or Shanghai if he knows for a fact that 1 in 5 team-members are on the verge of quitting. 

35 & unhappy at work?

How long does it take to get good at something? I mean genuinely properly world-class good? Good enough for the world to beat a path to your door. Good enough for you to consistently exceed the expectations of that world when it does.

The answer sort of depends on your chosen field but usually the answer is: -

Longer than you'd like

And certainly longer than every Internet self-help guru who says that whatever your age, all you've got to do is want something badly enough and put enough time aside for your ascent to be automatic. Even if you go buy some shiny Apple products to help you along the way.

Can we be honest? There are few fields of endeavour that you can enter for the first time at 35 years of age and make it to the very top. Even fewer at 40.

The obvious example is anything that requires extreme physical performance; only the deluded expect to become professional athletes after about 25.

But there are barriers even in seemingly non-ageist careers like Law when you do the maths. If you're going to start studying Law at 35 you're about five years away from actually practising and, unless you're truly exceptional, your chances of making partner at a Magic Circle firm are zero. At 40 you won't have the stamina to put in the hours required of an Associate. Of course you may still end up with a job that you love but can you honestly clock up the hours to get genuinely good?

Besides which, does the world really need another lawyer?

I've long envied those contemporaries who just knew what they were going to do in life. It gave them an internal consistency that translates into a massive career advantage. Early on they got called unimaginative and dull but as the years go by their ascents have come to be seen as inexorable.

I am not that person. Never was. I was the clever kid who, when told that he can achieve anything he wanted in life, believes it a little too much. Intoxicated by the possibility of everything led to years of focusing on nothing. Only in the past few years have I reconciled myself to the fact that I will never ascend to the top of any organisation because I've never shown the slightest loyalty to one.

People like me are plagued by the F Scott Fitzgerald observation that 'American lives have no Second Acts'. So plagued that often we never getting around to having a First Act.

So here's my tip: -

If you reach 35 unsuccessful and unhappy then you need to think very hard before cutting all ties with everything that's gone before in order to invent yourself anew. No matter how much you pretend to be a twentysomething just starting out it'll be clear to the world that you're older (but not wiser)

Any choice you make from now until retirement has to be informed by what you've done before, no matter how unsuccessful or unsatisfying it was. A change of direction is okay. As is a change of emphasis or company or country. All of these can be made to fit a narrative. What makes most sense is tracking down the coolest company in the world that does what you do now and taking a paycut to be there. Relocate at your own expense if you have to.

But that Brand New Thing that you've always liked the idea of doing? Well, sooner or later you need to accept that there's a real reason why it remains undone. 35 is about that time.

If my comedy was going to put me on TV it would have done so by now. But I would've had to have been monomaniacal in that pursuit from about 23 onwards and I wasn't. Now I'm 43.

I'm 43 and I'm writing this on a plane to Vienna where I have to make a lunchtime presentation before flying to Stockholm for a dinner with a different client. Neither company is the slightest bit surprised by my workload or my promiscuity. They value me and accept that others value me also. After all, I've been doing this gig (consulting to the health care industry) for fifteen years. I've earned the right to charge what I charge. Every day I set out to re-earn that right.

I acknowledge that I left it pretty damn late in starting my First Act. I also acknowledge that whatever I do next must be an extension on those last fifteen years, an elaboration at best. A complete departure would be a negation of all of that and be like diving back into a poolful of hungry twentysomething sharks.

I have accepted that in every other endeavour I will be no more than an enthusiastic, if perhaps gifted, amateur.

If you want to successfully change your life at 35 try re-reading your resume before burning it.