Francisco Machado 2002.
A frequent
issue with doctors, particularly GPRs is the fact that their surgeries often
over run. This tutorial is in response to concerns raised by one GPR about this
topic! I will look at this area by trying to answer the following questions.
Questions
w What’s the problem?
w Appointment time, what’s the best?
w When do I overrun?
w What do the patients want?
w When do I become anxious about time and what can I do
about this?
w How can I manage my time better?
What’s
the Problem?
Self reflection exercise.
What
do you find difficult about the time, or lack of it, that you spend with
patients?
Think of your last surgery where you
were running late, how did you feel?
The Time
Problem is…
w Probably
unique to UK GP, other primary healthcare professionals in other countries
enjoy much longer consulting times, e.g. a Swedish GP once told me he sees 8
patients on a Monday morning and spends half an hour with each one!
w Due
to trying to see a large number of patients in a short amount of time
w Exacerbated
by having a full day with little slack for the unexpected
GPs are having to….
w Deal
with complex issues
n
medical
n
psychosocial
w Cope
with the shift of workload from secondary care to primary care
w Manage
the change of emphasis from “individual” to “population” medicine particularly
with the implementation of NSFs. Trying to persuade individuals that they
should modify there lifestyle takes more time than treating someone with
earache!
w Act
as the gate keepers and will increasingly have to explain to patients why they
are not being referred to secondary care because their condition does not meet
“the referral criteria” set out by the NHS executive!
w Cope
with perceived patient expectations. “Targets and Charters” and the “24/7
culture” raise patients expectations of what they can expect from their GP!
Patients are often “better” informed and may present with material to discuss
with the GP without prior notice!
Time pressures can result in a
number of feelings including:
w Feeling
that one long consultation can “ruin” your schedule for the rest of the day
w A
feeling of panic if we run behind can result in “barriers” being erected by the
doctor
w Do
you let the floodgates open when you know that it is going to make you run
late?
w
Dissatisfaction for patient and the doctor
Appointment
Times
w Longer consultations é quality
w Probably takes a minimum of 8 minutes to achieve a
reasonable degree of shared understanding and management
w 10min appointment slot = 6 face to face consultation
time! There is so much else to do!
I
Will Overrun When….
Reflection exercise
What sort of consultations are
difficult to keep to time?
The
following may result in long consultations. How many do you recognise?
w Lack
of information, no notes or worse wrong notes, the computer crashes!
w Don’t
know the patient
w Patient
is angry or upset
w More
than one person in the room
w Patient
has communication difficulties
w Multiple
pathology
w
I am tired, upset, angry, anxious
What
do the Patients Want?
w Length of time is not as important quality of
interaction with doctor
n
Listens
n
Taken seriously e.t.c.
w “5 minutes of your undivided attention” On a short
counselling course I complained that I didn’t have the time to put into action
the skills I was learning as I was working on a busy O/G ward. The facilitator
reassured me that as long as when I sat with a patient the patient was made to
feel that she had my undivided attention that the patient would be happy!
w Doctor to recognise they have often waited a long time
to see the doctor of their choice. This is particularly important when you
become a principal. People genuinely will wait to see you.
Do
We Always Get Anxious About the Amount of Time We Spend With Patients?
Reflection exercise
When do you start looking at the
clock?
Clock
watching is more likely to take place when
w You get anxious. Anxiety may be a measure of how much
we dislike the patient sitting in front of us!
w When we have other tasks built into the day
w When the video camera is on!!
w Perceived pressure from others to see “fair share” of
patients!
What
Can We Do About It?
w Reduce our obsession with time
w Accept that at times every doctor will have a patient
who is in distress and will need a “long consultation”
w “If there is a torrential out pouring of pent up
feelings, we must just take a deep breath, offer the tissues, sit back and let
the day be ruined”
Case
Scenario
You are coming to the end of a
consultation with Mrs Jones who has come in to see you because she has a cough.
The prescription is printing and you spot that Mrs Jones looks sad. You smile
at her and you can see the tears well up in her eyes.
What
can you do?
Possible options.
• Ignore her.
• Pretend not to notice.
• Tell her to get a grip.
• Acknowledge her upset but say it is due to her cold
and will get better soon.
• Acknowledge her upset and send her to see the GPR or
nurse.
• Acknowledge her upset and ask her to make an
appointment to come and see you ASAP.
• Sit back, ask her if she is alright and find out the
real reason she has come. Give her and extra amount of time and listen. Then
plan follow up soon with extra amount of time.
How can time management strategies
help me?
w Appointment times and practice organisation
w Generic time management principles
w Consulting skills
w Difficult patients
Appointment slots
w Choose a time that fits in with your style and needs
w Conducting a time audit can help you identify your
consulting needs
w Anticipate patients and problems that will need longer
and book longer appointment times for these
w Gap or catch up slots during surgery
Time
Management Strategies
w Plan your day! Don’t fill every minute of the day!
w Agree when, who and why you can be interrupted
w Agree what you do about late arrivals
Before you see patients
w Organise you room!
w Organise yourself
w Remove annoying distractions out of site, or deal with
them before surgery, e.g. Phone calls, reports
General
Time Management Tips
w Parkinson’s law. Work fills the time available to it!
w Headless chickens! Forget being busy, concentrate on
working smarter!
w Pareto principle. 20% of effort results in 80% output!
Avoid perfectionism!
w For every yes there is a NO
w Elephants. Even elephants look small in the distance.
So large tasks may be seem OK and far off in the distance, but they soon loom
large and threatening!
w Salami. You wouldn’t eat a whole Salami at once, you
cut it up in to mangeable slices. Do the same with big problems, use the on-going
relationship with patients to manage big problems.
The
Consultation
Before the patient comes in
Be prepared!!
Read notes
w Summary card
w Hospital appointments
w Investigations
w Drugs
w Last visit
Peter Tate advises the following
strategies for making effective use of the consultation.
1. Determine the reason for the patient’s attendance at
the outset. This allows you both to set the agenda – what you will cover today,
what can be reasonably left for another occasion.
2. Determine the patient’s own ideas, concerns and
expectations before attempting an explanation so reducing the risk of a
“dysfunctional” consultation.
3. Use each consultation as a part of a learning circle.
Some tasks can be achieved over a series of consultations. This may change the
patients expectations of the use of time.
I have
found that the following result in shorter consultations:
w Let
the patient speak, try not to interrupt. Most will run dry after 2-3 minutes!
w Always
let them go first, anticipate why they have come but don’t let on!
w Watch
for cues and follow them up at some point but maybe not straight way. Avoids
door handle consults
w Demonstrate
you care and the patient is likely to tell what they are really here for!
w
Identify early if the patient has more than one issue
to discuss. Particularly before examining them. “the couch game”
Be
alert and recognise how you deal with:
w “List” patients or “I don’t know where to start”.
Don’t get annoyed! They are being honest. Ask them to list what is wrong. Often
they are related in any case!!
w Patients you don’t like
w Conditions you have never managed (often the patient
will not what to do…don’t panic)
w Angry patients and the feelings you have may reflect
what the patient is feeling.
Your
demeanour.
w Be assertive with the patient and others.
w Avoid padding and repetition.
w Keep cool and in control.
w Smile, it really helps!
The
Long Consultation
w Can you chunk it? See the Salami above!
w Explain you need more time and arrange follow up soon.
w At times accept some patients will take time
w If you can anticipate a problem will take time book it
so that you have more time
Getting
the Patient Out of the Room
w Close the file
w Look away
w Stand up
w Comment on how nice the weather is
w Help the patient with their coat
w Open the door
w Wear an evening jacket!
w Pretend to have a grand mal convulsion
The last
two are recommended only to be used occasionally by Peter Tate ;)
After
the Patient Has Gone..
w Write up notes.
w Dictate letters.
w House keeping.
w Take time out to prepare for next patient if required.
If you
are running late
w Inform patients via receptionists, good PR exercise!
w Acknowledge you are running late when patient sees you
but make them feel that you are not going to use them as an opportunity to
catch up!
w Don’t get into long arguments about time and why you
are late
w Smile! It really works!
And Finally
w Remember you are not alone
w With experience and the development of your consulting
skills your time management will improve.
w You will eventually accept the risks you take in
general practice
w Have fun and guess what………….Keep smiling!
Resources:
Peter Tate.
The Communication Handbook?
John
Salinsky. What are you feeling Doctor?
Managing
your Mind.
FM MMII