Time management

Case study

Doctor Emily Jones completed her training 2 years ago, and is currently a salaried GP working in a busy practice. She is worn out. During training she found it difficult to keep up with the rate of work expected of her, but she had believed that this would improve with experience. However, she still struggles to get through surgeries on time and she considers herself to be the ‘slowest’ of the four salaried GPs in her workplace. She regularly leaves the surgery late and takes work home on a practice laptop.

She approaches some experienced GPs in the surgery for help. Dr Carter is the senior partner and is sympathetic to her situation. He assures her that the practice is happy with her work, but understands the impact of this situation for her. They hold a series of meetings focusing on the different factors that they agree are impacting on Emily and why she feels she is falling behind.

After 6 months of adjustment, Emily considers that she has improved her efficiency in many ways. She thinks that she might never be a very fast GP, but that her current working pattern is more consistent with fulfilment in work and at home.

The complexity of general practice

The number of fully qualified GPs per 1000 patients in the UK has been falling steadily since 2015, and this dwindling band are being asked to do a greater range of tasks for complex patients (British Medical Association (BMA), 2023.) Therefore, GPs need to manage time optimally in order to best serve their communities.

Time management in any life role involves accounting for all the small tasks and processes that make a claim on one’s time, prioritising, and seeing how they should best fit together. This is usually a complicated undertaking, and even more so for GPs. GP consultations are intensely complex interactions that take place in workplaces where an increasing mosaic of overlapping roles, referral processes and external inputs must be negotiated on behalf of patients. GPs need to have oversight of this mosaic in order to understand how to delegate effectively and where to invest time where it is most needed.

In the consultation

When GP trainees are learning to improve their consultation skills or preparing for a skills examination, they are aware of the enormous pressure of fitting all of the required consultation tasks into 12 minutes, and the fear of leaving something out. This may be the reason why so many candidates find it difficult to accommodate the consultation techniques recommended and taught by their trainers.

Such techniques include asking about, and making use of, the patient’s ideas, concerns and expectations, and their psychosocial background; developing rapport through active listening and maintaining curiosity about the patient’s perspective. Trainees often feel that some of these skills will open a Pandora’s Box and be detrimental to their time management. How can listening to the story of the patient’s cat’s illness help get through the three medical problems that this patient has presented with, in the time available before the next patient is due to arrive?

For these doctors, it can be helpful to think of the rapport that they build by focusing on these aspects of the patient’s experience as money (Teaching and learning consultation (TALC), 2022a.). When GPs build rapport, they are depositing cash in the bank of the doctor–patient relationship. Later in the consultation, this will be vitally important. The patient will trust the doctor’s suggestions for medication changes, they will be better motivated to engage in lifestyle changes, and they will agree readily to defer one of those less important problems until next time, all because the GP can now spend the rapport money they have accrued. This version may sound idealised, but it is a model of human communication that has been extensively studied and evidenced by scholars of the consultation over decades (Moulton, 2016).

Many of the benefits of adjusting consultation habits take time and practise to develop, but there are some quick wins. One example is the BATHE technique for the effective and succinct delivery of empathy to a patient (Stuart and Lieberman, 2019). A talkative patient who is upset by their illness will wish to spend time ensuring that the GP understands how a problem has affected them. A GP who tries to offer solutions to their problems, without first having demonstrated that they have understood how bad the problems are, is unlikely to succeed. The BATHE model is easy to learn and can be adapted to suit the user and the consultation. It is suitable for use in a large proportion of GP consultations. See Fig. 1.

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Figure 1.

The Bathe model of empathy.

Another rapidly attainable skill to save time in the consultation is effective agendising. Problems that arise late in the consultation, those ‘while I’m here doctor’ moments, affect time management significantly, as they are not budgeted for by the consulter. Most patients do not understand this to be a problem, so they should be encouraged not to do it, and this should happen early in the consultation so that time can be planned better. Here, the exact wording of the doctor’s request to set an agenda is the key. ‘What else did you want to talk about?’ risks the development of a shopping list of issues that the patient brings up only because they have been asked to do so. ‘Is there anything else that you were planning to talk about?’ works better, because it is a more precise conveyance of what the doctor wants to know (TALC, 2022b). Another important tool to learn early in GP training is the summary. Moving beyond echoing the patient’s words while listening, GPs can employ a summary at the end of a section of the consultation. Doing so allows them to summarise not only the details of the presenting problem, but also its impact on the patient including psychosocial aspects. Thus, the clinician consolidates the history for themselves, and reassures the patient that they have understood the extent of the problem (TALC, 2022c).

Use your tech

Optimal use of the available information technology can improve time efficiency in a number of ways. GPs, like any professional who uses a keyboard a lot in their job, should consider investing time in learning to type fast and accurately. If spelling accuracy is kept above 95%, then aiming for at least 40 words per minute (considered an average typing speed) is a reasonable target for someone who types every day at work (Typing pal, 2022). In addition, most electronic patient record systems have a range of options that are designed to help people enter data more quickly. Synonyms (such as EMIS Quick codes, Fig. 2) allow users to add a large chunk of text (such as a commonly recorded examination finding or an explanation to a patient) by typing a few characters. Users can add their own personalised synonyms.

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Figure 2.

EMIS Quick codes. These are accessed by first clicking on “CR Config” in the consultation screen ribbon.

Another timesaver is the use of keyboard shortcuts. They allow users to navigate to the correct section of the software system without reaching for the mouse. The benefit for each instance is measured in seconds, but over the course of the day this translates into significant time saved. Figure 3 describes how keyboard shortcuts can be quickly learned and customised.

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Figure 3.

EMIS Keyboard shortcuts. These are accessed by pressing the alt key and then pressing the key or sequence of keys needed to reach the chosen destination as per the pop-up labels shown. So, to reach the appointments screen, press alt and then press E (which opens then EMIS menu seen in the second picture) and then A for appointments and then return.

Another way of saving time is to avoid navigating from one screen to another altogether and instead to access the information that is needed (for example, recent blood results) from the screen on which one is already working. This is facilitated by some recent software innovations. Hovering over the alert on the bottom right of the screen, opens overlaid summaries of information needed to make decisions, as seen in Fig. 4. Thus, the user does not entail delay by navigating to a new screen.

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Figure 4.

Overlaid summaries of results and monitoring.

Staying sharp

Outside of the consultation itself, general practice generates a large amount of work in the form of referrals, pathology results to be processed, medication reviews, correspondence and a plethora of other tasks. The profusion and diversity of tasks can itself be a source of stress, particularly when the tasks are difficult to enumerate and it is unclear how long each of them will take.

Commentators on improving workflow and productivity discuss the need to enable focus on the task in hand (Allen, 2019). This can be achieved by making sure the tasks that are left to be completed for the day or for the week are recorded not in the person’s memory alone, but in an external system, be it pen and paper or an electronic to do list. This can be accompanied by an estimate of how long each task is likely to take. Doctors can free up cognitive bandwidth by removing unfinished tasks from their working memory and offloading them in this way (BMJ, 2017).

Removing the stress of having to recall the remaining tasks is a first step to improving attention to the task in hand. One additional trick is to set timed work and rest periods using the Pomodoro Technique (see Fig. 5). This technique aims to enforce a break before concentration and motivation dip. The task can then be resumed after a short break. Another trick is to try to complete any task that is likely to last only 2–3 minutes straight away, rather than having to add it to a to-do list. The fillip of picking off ‘low hanging fruit’ before they reach the to-do list can provide a motivational boost.

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Figure 5.

The Pomodoro technique was named after the tomato-shaped kitchen timer that inspired it. Francesco Cirillo discovered he could improve his productivity if he worked in blocks of 25 minutes, each followed by 5-minute rest periods. (Giesbrecht, 2015)

Front-of-house systems

As a scarce resource, appointment time should be allocated according to individual patient need. In the absence of an effort to democratise access, the default system of first-come first-served, resulting in queues of patients at the desk or on the phone at 8 am can have negative impacts on patient satisfaction (Atherton et al., 2018). It can also result in patients attending in person for problems that could have been better dealt with remotely.

Many surgeries will triage all appointment requests and phone some or all of them before allocating face-to-face appointments. A new development over the last few years is electronic asynchronous messaging between patients and GPs. One of the early innovators in this area was the private company Babylon and their NHS venture ‘GP at Hand.’ Their arrival, championed by Health and Social Care Secretary Matt Hancock in 2018, presented a challenge to GPs in those cities where Babylon operated (McLellan, 2018). It is indicative of the ability of GPs to adapt and take on such challenges that Babylon’s digital innovations have since been assimilated by many surgeries and incorporated into their triage systems. Babylon’s share price, meanwhile, fell by 90% after it debuted on the Stock Exchange in October 2021 (Criddle, 2022).

There are several information technology (IT) solutions that enable electronic consulting: Ask My GP, EMIS Online Consult, PATCHS and Accurx, to name a few. These can save time because the patient provides information directly to the GP including images or videos, and the GP can request clarification or make suggestions, or decide whether they need to speak to a patient on the phone or see them face-to-face. Some tasks may be streamed to another team member. Others may be completed entirely via text communication. A recent analysis found that 72% of all patient interactions within such a system were initiated online rather than by telephone or in person (Perry, 2022). GP specialty trainees (GPSTs) may find themselves working in a practice using one of these new systems, and this can present learning opportunities as well as challenges. Each system has orientation guides (see Figure 6) and these should be explored at induction so that the system can be used efficiently. Practices often have one staff member who is a virtuoso in IT systems and inductees can also make use of that person’s expertise. GPSTs will usually not be asked to manage telephone or online triage early in their education, but it is a skill that should be developed before completion of training. GPSTs should be aware of the limits of online consultation systems when using them. A patient cannot be physically examined and there is a huge loss of nuance in communicating by text as opposed to face-to-face. However, these systems can be used to stratify urgency and identify those patients likely to benefit most from face-to-face appointments.

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Figure 6.

Orientation guides for a variety of clinical IT systems.

Use your team

Currently, 19% of GP consultations involve a musculoskeletal problem. Concerns about medications are involved in 41% of consultations (Salisbury et al., 2013). Increasingly, GPs working together in primary care networks (PCNs) have access to clinicians who can take some work off their hands, such as first-contact physiotherapists, dieticians, mental health practitioners or clinical pharmacists. The key to success in delegating patient contacts to other healthcare professionals is to ensure that one understands the roles and skills of these colleagues and that this information can be passed on to the patient in a proactive, positive way. Patients for example, may not already understand the difference between a physiotherapist (many patients already have experience of physio: for example, they saw the physio in the past about their knee rehabilitation) and a first-contact physiotherapist, whose role it is to assess, diagnose, arrange investigations, advise and sometimes prescribe for the patient. Misunderstandings can be avoided by sending a message to the patient explaining all of this in advance (see Fig. 7).

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Figure 7.

Suggested message template to introduce a patient to a first-contact physiotherapist.

GPs also need to ensure that they use the non-clinical staff in the surgery to their full potential. The GP may not always need to phone the patient to deliver a straightforward message for example, and they can ask the admin staff to do this instead. Non-clinical staff can improve the efficiency of the whole practice and trainees should speak to them, informally and in ‘whole practice’ meetings to learn from them about how they can help.

Prioritisation

As well as delegating tasks to others, GPs need to be able to rank the priority of tasks that are suggested to them by various external agents, often prompted through the practice computer system. Guidelines from every professional body would like to stake claims on the time of GPs. It has been shown that if clinicians followed the advice of all available guidance their time would be used up many times over (Johansson et al., 2023). This has prompted the emergence of the concept of ‘Time Needed to Treat’ (TNT). Treatments are often recommended based on metrics such as ‘Number Needed to Treat’ (NNT) which measures how likely a treatment is to be effective across a population of patients and allows guidelines panels to make evidence-based recommendations to clinicians for cost-effective care. However, guidelines panels seldom consider how much time the intervention takes overall and what that time requirement means in general practice. For example, if the 2013 NICE guidance ‘Physical activity: brief advice for adults in primary care’ were implemented in full and applied to all eligible adults, it has been estimated that this would account for 15% of a typical GP’s total face-to-face time with patients. GPs will realise that this advice could be beneficial for some of their patients, but also know that it is one directive out of many. Most GPs will agree that it is unlikely that they will be able to implement it across their entire practice list without leaving out other important work. If guidelines bodies considered TNT, then they might hesitate to strongly recommend the implementation of interventions, such as these for all patients in primary care. Since they do not, it falls to GPs to do the task of prioritising rather than simply following guideline recommendations.

In practical terms, what this means is that when a patient attends general practice, the clinician seeing them should allocate time first of all to the reason for the patient’s attendance: their ideas, concerns and expectations and their conspicuous health needs, before moving on to consider the other things that stake a claim on consultation time, often from the reminders popping up in the corner of the screen.

Understandably, organisations will want to maximise their income, and incentivised work from things like the Quality and Outcomes framework and Enhanced Services contribute to money that pays staff wages. Even GP partners and managers, however, will recognise the primacy of dealing with the presenting problems on the patient and doctor’s shared agenda, before attending to this additional work.

Quality improvement

Many will wonder how a reference to quality improvement makes its way into an article about time management. It is a mistake, however, to think of quality improvement as something that is done as an add- on to clinical practice, or to satisfy a requirement of training or appraisal. Good quality improvement projects (QIPs) will arise from the inefficiencies that are sucking time out of the day of a working GP. When they are done well, with team involvement, they can free up time for many stakeholders in the practice, as well as improving quality of care. To put this into practice, time should be allocated to thinking about the problem, the aims of the project, and how it should be carried out. Learning how to carry out a good QIP during training is an important way to ensure that GPs can seek out the inefficiencies in whichever system or organisation they work and begin to minimise them. This can improve time management, quality of care and job satisfaction. GPSTs carry out a QIP including a structured assessment during a GP post in the ST1 or ST2 year and should set aside time to plan this project and its associated learning early in their training (RCGP, 2022).

Know your boundaries

The impact of suboptimal time management can be very severe, reducing a GP’s enjoyment of their work as well as reducing their leisure time and impacting on their sleep, mental health and family life (BMA, 2019). However, some of the remedies for this problem can be difficult to implement. Just as in any therapeutic decision-making process, the potential benefits of improving a GP’s time management should be weighed against the likely downside of new strategies. There will be initial time costs to learning new ways of working.

Some GPs may re-assess their work pattern and decide that they need to adjust the amount of time that they allocate to each patient. A series of 30-minute appointments throughout the day, leaving each successive slot increasingly delayed, is likely to reduce of happiness of both the doctor, and of those patients who are delayed (Mirza, 2016).

Nonetheless, when a GP is used to devoting that much time to a patient’s problems and their patients are also used to this level of service, there is the prospect of some tension during remodelling. The consultation skills referenced above will prove invaluable and are a central part of timesaving in the consultation, but it should be acknowledged that, when available time is constrained, there are occasions that GPs may fail even when armed with these tools.

GPs should understand in advance that the aim of better time management is to improve outcomes for themselves, the greater number of their patients and their teams. There may be moments when individual patients react unfavourably to a reduction in access or appointment time. Is this ‘side effect’ too much? The GP involved will have to decide for themselves whether the time is right for them to take on these challenges. The process may be one of gradual incremental change, but trainees should bear in mind that the patient’s expression of urgency will not automatically mean a GP emergency: triaging according to clinical need is the doctor’s responsibility. Consultation techniques such as summarising the patient’s story and acknowledging the emotional meaning behind what the patient is saying can help prevent negative reactions. Listening carefully to the patient and building rapport, as discussed above, can enable the GP’s confidence that they can impose structure on the consultation, agendise co-operatively and lead the way towards an agreed conclusion to the consultation.

There are some GPs who routinely run behind and do so in the knowledge that they are constraining their leisure time outside of work. Such doctors may consciously accept this situation, or even see it is part of their professional identity. This is a personal choice, and is not wrong or incorrect, but neither should it be valorised or seen to be something to which most GPs need to aspire. Giving time beyond normal limits can provide benefits for individual patients, but in a system of constrained resources, doing this routinely for each patient can impact on care provision to the practice population as a whole, result in increased waits for pre-booked appointments and impact negatively on the GP’s wellbeing.

Managing uncertainty

Diagnostic uncertainty is inherent in primary care even more than in hospital medicine. History taking is more compressed, tests are not readily available, and they are more difficult to interpret when the pre-test probability of disease is low. There are GPs for whom this uncertainty results in prolonged decision-making processes including rumination on the various possibilities and outcomes. Many GPs carry these concerns home and lose sleep over them. This may be accompanied by a trainee GP feeling the need to routinely seek advice on every case from a colleague or supervisor. To be clear, trainees are encouraged to discuss cases with supervisors, and trainers will sometimes stipulate that each case should be discussed, particularly in the first GPST placement. However, as the trainee gains knowledge and experience, many trainers will switch to a ‘clinical debrief’ which will not include detailed discussion of every case unless the trainee requests it. This leaves room for educational assessments (such as case-based discussions) which can work better when cases have not already been discussed in detail. If a trainee does not feel comfortable following this lead and still would like to discuss every case in full, and if that trainee is also running late and not seeing as many patients as expected, then there may be an educational issue related to managing uncertainty.

Living with uncertainty is part of life in general practice. This can require an attitudinal shift when doctors are used to finding out what is wrong with every patient before they leave the hospital and go home. The understandable source of anxiety is that a patient will have a bad outcome, or that the doctor will be responsible for missing a diagnosis, or that the patient could become seriously unwell or die. Some of these negative outcomes are unfortunately frequent occurrences in general practice, therefore life as a GP has the potential to be an engine for anxiety. This in turn can result in anomalously high referral rates and high levels of investigation (Foot et al., 2010).

This can be at least partly remedied by replacing the aim of avoiding any negative outcomes with a more realistic aim that we should practice in a way that provides an excellent chance of reaching diagnoses that we could be reasonably expected to make (Danczak, 2016). This is in fact all that our patients and our colleagues expect of us. Practicing in this way can make better use of resources, including patient and clinician time, and is consistent with lower levels of patient anxiety and fewer unwanted incidental findings arising from clinical investigations. The benefit in terms of time management is chiefly that the GP making decisions is freed from the need to ruminate on all possible outcomes. Instead, they can think about probable outcomes, how to interrogate or investigate the situation appropriately, and how to follow up and address the next step in the process once more information is available. This attitudinal shift should not be expected to happen overnight, and holding discussions about balancing risk with avoidance of over-investigation is a good start. Colleagues and supervisors will be happy to discuss these issues, and when the doctor feels ready, patients are often grateful for this dialogue as well.

Key points

Attention to consultation skills will enable more efficient and effective consulting and some of these skills can be learned quickly