Time Management: How to work better in Primary Care

Do you find time management in General Practice a challenge?

We kick off this season with some episodes addressing the all-too-familiar problem of managing time in Primary Care, both within and outside of the consultation.  In this episode Dr Munir Adam speaks to a GP who has a lot of good advice to share with us about how we can manage our time more efficiently. 

SPECIAL THANKS to our guest speaker: Dr Ed Pooley; GP and author of the book Managing Time in Medicine.
 
USEFUL LINKS:
1.  https://www.facebook.com/groups/difficultconversationsinmedicine/
2. mybook.to/MTIM
3. Managing time in Medicine course:  https://tenminutemedicine.podia.com/managing-time-in-medicine
4. Assertiveness and Saying No course:  https://tenminutemedicine.podia.com/burnout-to-brilliance-assertiveness-and-saying-no

SEASON 2 is supported by funding and back-office support from Integrated Care Support Services.  ICSS supports practices and ICBs with Projects, Training, Resourcing and back-office support. (www.integratedcaresupport.com).

Transcript available on website.

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Specifically, this podcast is NOT intended for use by the general public or patients and must not be used as a substitute for seeking appropriate medical or any other advice. Views expressed are the opinion of the speakers, is general advice only and should not be used as a substitute for seeking advice from a specialist. Healthcare professionals accessing information must use their own professional judgement, and accept full responsibility when interpreting the information and deciding how best to apply it, whether for the treatment of patients, or for other purposes.

(C)Therapeutic Reflections Limited.

Transcript

Munir Adam: 0:06

Hi, and welcome back to Primary Care UK, the podcast for you, the busy frontline clinical staff working in primary care. I'm Munir Adam, and today we start season two and we're gonna start this with a few episodes to do with the all important topic of time management. First of all, we thank those of you who have stayed with us during season one and for the positive reviews and feedback, and based on that, we decided that going forwards, we'll have a main episode released at the start of each month, and then a mini episode on the 15th. And the time management series of which we'll have a few episodes is going to be on the main i.e. at the start of each month, and also from the feedback, we'll now also be including transcripts as well. So let me start by asking you what's worse than having very little time to do anything. It's when you spend your very limited time listening to somebody talk about time management and actually telling you things that you already knew. Somebody who simply tells you about the problem or give solutions that anybody could have worked out. That can be so annoying, and so we've tried hard to make sure that we're giving you actual usable techniques that you'll benefit from, and we really value your feedback in terms of whether we've actually achieved to do that or not. In season one, episode nine, we talked about the big problem that we find in terms of time when doing consultations. We talked about some of the reason regarding this and the impact that it has and that something must be done. I promised I'd come back with an episode talking about some of the solutions or ways forward. Well, actually, we have a few episodes lined up for that. Not only that, whereas initially I thought I'd do this; after being late in surgery for the thousandth time, I realized I probably wasn't the best person for the job. And so I've been speaking to a few, what I call experts in this, and also many of you, because we all have tips about how to do things better. In this episode, we're gonna kick off with the discussions with Ed Pooley, who's published on this topic as well. And the question is this, while we're waiting for the world around us to change and make things better, what is it that you can do to improve your time management?. And so the relevance of this episode is to all of our listeners. So let's learn together. I'm joined now by Dr. Edward Pooley, who as well as being a GP and trainer also has an interest in communication, time management and things like that. He's author of the book Managing Time in Medicine, which is about developing efficient consulting skills in primary care. And he also has his own Facebook group about this kind of thing, and it's actually proving to be quite popular, so you might wanna check it out. Perhaps we can say a bit more about that towards the end. Ed, it's great to have you with us. Is it okay to call you Ed?

Ed Pooley: 2:55

Please do. I'm happy to be called Ed, and thank you for inviting me on today.

Munir Adam: 2:59

Now, Ed, I suspect that most listeners want to hear from you more than anything else about how to manage their time better, both within the consultation and outside the consultation as well. But before we get onto that, I just wanna say that, while I hope that most listeners are gonna be listening with an open mind, there are gonna be cynics out there, aren't there? Some people are gonna be pessimistic. Working in the NHS has always been busy. It's always going to be busy. We've got an ever increasing amount of work being thrown towards us and that there's nothing we can do about it. What would you say to those listeners?

Ed Pooley: 3:33

I, I think I'd say I entirely get where you're coming from. In the NHS we often have good ideas thrown at us, and we have tips and techniques all the time that are designed to be the next big thing. I think the difference with my approach is that, the book that you mentioned, it looks at things from a systems perspective. It looks at the three features. It looks at what we can do to influence things with the patients, with our own consulting time within the systems we work. And I think today the focus is gonna be the patient and also how we consult really, because those are often the areas where people have the greatest control. If you're a GP partner, then yes, you may be able to influence the system more, but if you're, say a salary GP or an A N P or somebody else working in primary care, what are the things that you can do to improve time? And I think one of the most helpful things that certainly helped me was breaking down what you do into a series of tasks. So it may be that you can change the way that you ask questions so that you don't have to ask repeated questions. It may be that how you introduce yourself to the patient will save you time. Uh, it could be that the way you document things will save you time. So I, I see time management as something to be done by incremental steps. You try and you keep what works for you. If it doesn't work for you, then you move on to the next tip. By no means do I think time management should be overly dogmatic or you should try and shoehorn in techniques that just don't work for you or your organization.

Munir Adam: 5:07

Hmm. I think that's completely valid point to make really about control bit you mentioned, I think when you. Pessimistic. When you're negative, we often find that we end up concentrating on all of the things that are not within our control, and then blaming everybody above ourselves, but actually focusing and breaking it down into those three categories, as you just mentioned, can really highlight that point that a number of those things are within our control. Okay., I hope that convinces some more people out there to actually join this with an open. If we don't have hope, then what do we have? And that's not to say that, that we don't have any ever increasing amounts of work and so on. Yes, we do. The other thing that I wanna just say is, and I know this is stating the obvious, and you just referred to it yourself, which is about context. And yes, of course, it's context dependent. So a nurse practitioner or perhaps a physicians associate doing a diabetes review, for example is gonna need a different range of strategies and approaches, perhaps, than somebody who might be a clinical pharmacist doing a complex medication review, which again, is different from a GP following up somebody for their abnormal blood test results, which again, is different from, say, an FCP doing a musculoskeletal assessment for the first time with a patient presenting with some sort of MSK problem. So not every strategy is gonna work in every situation and interpreting it in the context of the scenario and the... Is that a fair thing to say?

Ed Pooley: 6:30

I think so. I think the way that I would add a little bit more nuance into that is that, there's two aspects. There's opportunity and there's strategy. With all of those roles that you just outlined, you're talking about a situation in which a healthcare professional is bringing a person either back to clinic or is preparing to have a consultation with them. The opportunity here is that there may be stuff that you can do prior to that consultation or that interaction that makes things easier during the interaction. So let's say if we take the example of someone who is coming in for a smear test, maybe one thing that you could do is send your patients who are coming in for smear tests, some sort of information about what to wear to make that more easy, so that you're spending less time taking layers and layers of clothing off. Maybe you are answering a few questions upfront so you don't have to answer the same questions over and over again. Maybe you are providing consent or, or some sort of information upfront so that the person knows what to expect when they come in that shaves two or three minutes off your consultation. Those are the things I would look at. So I would differentiate into opportunity and then the individual strategy that you might want to apply.

Munir Adam: 7:43

Okay, so opportunity and strategy. We'll try and bear that in mind. Okay, so let's do this by starting with a situation that many of us find ourselves in. You know, I'm a frontline clinician and I'm working in primary care, and I'm struggling to cope with a sheer amount of work that's being thrown at me. Where do I begin?

Ed Pooley: 7:59

I think the first thing to do is to take stock and see what's comprising your workload.

Munir Adam: 8:04

Mm-hmm.

Ed Pooley: 8:05

And traditionally, time management strategists have put this into three categories.

They are: 8:12

Value demand, which is the stuff that you should be doing day to day that no one else can do. Then there is something called internal failure demand, where we are picking up the pieces from work that we inadvertently create ourselves. So that might be where someone has come back to, to hear that their blood tests are all normal and there was no further action. We could have dealt with that in a different way. Uh, it could be where someone has come for a second opinion because they, they got booked in with a doctor that they didn't want to see let's say. Those are common examples of internal failure demand.

Munir Adam: 8:47

Okay.

Ed Pooley: 8:49

External failure demand is where we in primary care, pick up the problems from another system failing. So really common examples of this are writing med threes or sick notes for people who've been in hospital. Um, Converting hospital prescriptions to outpatient prescriptions, for example uh, answering questions that specialists would be a better place to follow up. All of these sorts of things. And I think if you know what the proportions are that you are dealing with, you can then shift your focus to dealing with them individually. So we like value demand. We like doing the stuff that we're supposed to be doing, that only we can do. The one we probably like the least, is external failure demand. So you know, if you look at strategies such as the BMA letter template system where we get someone to just send back letters every time it happens to say, this isn't our job going forward, please will you sort this out yourself. It eventually gets the message across. But we do need to build our assertiveness and confidence skills to be able to say, look, I'm really sorry and I know you feel like you've been messed around. But this is not our role and we don't have the capacity to take on this role. Our role is to focus on the stuff that we are good at rather than being some sort of community house officer. That would be where I would start the first step to any implementation of change to understand where you're at now and what the biggest factors are that are influencing what you do.

Munir Adam: 10:18

Right. Okay. So actually when you explain it that way, what that is telling me is that there are those three categories, and actually it's just the first category out of those that is work that we should be doing, and that's what we feel value in and that's what we like to do. You mentioned internal failure demand. An example that was going through my mind, and this is something I was discussing with a couple of my GP trainees just recently, and it's a common thing where, when clinicians feel that they're not going to manage something within the time available, they come back to it later. And then when you have to revisit something in the consultation, you have to open the records again. You have to remind yourself, you re-read some paragraphs, and then you do what you could have actually done straight away. If you had addressed it and just executed it at the time. So doing things contemporaneously, I found often helps even if it means you run slightly behind. And then you mentioned external failure demand, and yeah, definitely. I'm very familiar with this scenario from um, a lot of work being thrown at us from hospitals. And actually, if you pose this to, I dunno, partners in the surgery or PCN directors, you might get an answer, oh, we haven't got the time to address. But sometimes investing a little bit of time earlier might actually pay dividends,

Ed Pooley: 11:31

I, I agree. I think in terms of when you are dealing with external systems, Be it social care or some sort of secondary or tertiary care system, often it's better to be proactive than reactive. So for example, one, one strategy that I encourage doctors to do when they refer people is to explicitly say things like, you'll be seen in probably X timeframe. In order to get the most out of that consultation in secondary care, you know, read up about the condition that you've got, read up about what might be used as a way of helping you or treating you. And then there's a couple of things that you'll need to bear in mind when you go to the hospital and that is that your medication will need to be coming from the hospital so that it's done in one go. You'll need to get your sick note from the hospital and often just give them a sheet of paper that just outlines this sort of process. That does two things. One, it strengthens the relationship between primary care consultant and patient. Cause you are effectively giving them a heads up about their patient journey which tends to improve continuity of care. Uh, and patients like it as a sort of a value added. And then you turn the patient into your advocate because they're then saying, actually no, I understand. I can get my sick note from you is what my GP has already said, so that if that relationship breaks down, the patient is to some extent, already on your side.

Munir Adam: 12:54

I like the sound of that because patients like to feel empowered, don't they? And it's very easy for us to assume and to know these facts., a hospital doctor, for example, can do a sick note. But actually, why would a patient being referred to the hospital for the first time know this unless we tell them? So I can add this to my list. You know what I often say to patients when I refer them these days is: make sure they follow you up until you are satisfied that your problem's being addressed. So you've just given me two more things to add to that list. Just going back to those three categories you mentioned, I think that I often find it very easy to identify what it is that I should be doing and what it is that a third party organization should be doing. But it's the second category , you know, when we talk about unknown unknowns, you know, maybe I'm doing things in a slightly inefficient way and I'm therefore duplicating my work without knowing it. Is it easy to identify what those things are, where we're wasting time?

Ed Pooley: 13:49

It's not because we can sometimes get sucked into feeling good about ourselves when we get a positive feedback loop set up. One of the things that's certainly changed in my practice over the last three to six months has been, uh, depression reviews. So I'll see someone initially at a consultation when we talk about their mental health and we have a plan to maybe start, you know, they're gonna give the talking therapy a service, a call, and they're gonna give them, they're gonna give them a ring and they're gonna find. I would normally, in the olden days,, it's sort of pre pandemic when, when everything felt, much like we had more resources available, would be to bring them back at, two weeks or four weeks and say, well, how's it all going? And build the relationship. One of the things that I find works phenomenally well now is to say, well, what I'm gonna do is, this is our meeting today. At any point, you know, you can ring up the surgery and we can schedule an appointment if we need to. But what I'm gonna do is I'm gonna set up a scheduled text message that's gonna check in with you in two weeks today, and it's gonna ask you how you've got on and whether you need anything from me. And if you need anything from me, we'll book it in as an appointment when we've got the chance. If you don't need anything from me and you're doing okay, Then just drop me a message, click on the link in the text message and let me know how you're doing. And about 50% of people just go, I've spoken to the therapy service, everything's going well. Thanks so much for your support, doctor. And then that's been it.

Munir Adam: 15:17

And you can do that. Can you, I didn't know this.

Ed Pooley: 15:20

Yeah, so if you have so I, we use a system called Accurx, which is sort of revolutionized a lot of the things I do in terms of time management. I know there are other systems available at M Jog and I think System One has some inbuilt stuff as well, but particularly Accurx, there's a scheduled text message function, so you can set it to deploy the text message in a week, two weeks on a custom time and date. And what that does, the patient feels very much that you are their doctor helping them through this journey because it feels much more familiar in relationship building to receive a text message than for you to just say, I'll book an appointment in a week when you've done something. The other thing is that it then automatically records their response in the notes, and it shows that my, my plan going forward is to check in with them in a month, in a month or a week. It's already set up in the notes. So again, that's less time documenting. That's less time writing out in what your plan is.

Munir Adam: 16:20

Incredibly. Yeah, because very often, I have to admit, I would just end up phoning them and sometimes you don't get through the first time. And then not only that, but when you do get through, it takes longer on phone call than perhaps receiving a text message that you don't even have to send because you've set it up; and then you don't even have to document it cuz the Accurx message that they respond to, and their response, will be documented in the notes automatically.

Ed Pooley: 16:42

Absolutely, and uh uh, there are other ways that I use this as well, so as well as using it retrospectively. Let me talk about another example that saved me an awful lot of time. I'll use it for kids with coryzal symptoms or who are a little bit unwell. At around about a week to two weeks, and I'll say something in the text message like I hope name of little one is doing okay; things just to keep an eye out for making sure they're eating and drinking. You may notice that they're coughing a little bit, but hopefully this will diminished. Um, if it's not diminishing, if there's anything you worried about, just drop me a text back and we can have a phone call, book that in if everything is going okay. I would expect the symptoms to resolve by, and then I'll give a date. So I'll say for example, February the end of February. What I tend not to do now is to say things like in one week or in two weeks, cause people lose the initial frame of reference

Munir Adam: 17:37

Hmm.

Ed Pooley: 17:38

whereas people tend to remember more, oh yes, he said the end of February, or he said the first week of March or the second week of March.

Munir Adam: 17:43

Yes.

Ed Pooley: 17:44

And then patients then have something to hand the next time their child gets ill. Oh yes, the doctor is looking at their hydration status, their cough, their symptoms, what their behaviour's like, so that you, what you are doing is you are subtly building in coping skills and strategies that they may not have. You've given them something to refer to and you've checked in and, and again, those are people who may have come back before and said they're still not right. Are they okay? I just wanted their chest checking. All of these things that use up time when perhaps they don't need to or, or may result in you trying let's say strengthen the front door so that your receptionists tend to back these away actually is now turned into something that is very much more relational. The patient recognizes that you care about them and it's cost you very little effort and has written your entire follow up management plan in it because it's in a text message.

Munir Adam: 18:38

Yeah, that you know . That's incredible actually, because it's so simple. And yet I was thinking about the benefits of this., you've just highlighted them, but you know how we have patients presenting with problems and then we do say to them towards the end that this is going to last however many days. But actually if you are suggesting a follow up on a particular point in time, you've essentially reinforced the message that this is how long it may take, because we don't always do that, do we? We're very vague in terms of asking them to follow up if things don't get better.

Ed Pooley: 19:09

I think we fall into what we call schematized, ways of talking. So we all have these patterns and expressions that we use day in, day out, and we often apply them without thinking because it, it requires less cognitive overhead. So we'll say things like, uh, call back if it gets any worse, which is great that, you know, that's a nice throwaway comment until the patient calls up reception and there's no appointments. And then the patient says, but Dr. Pooey told me to call back. What am I supposed to do? And then the fear increases, the panic increases, and then all of a sudden you are left with conflict at reception. And then the receptionist is saying to you, why on earth do you tell the patient to ring back? We've got no appointments. And it's just, it then just creates stress.

Munir Adam: 19:51

Mm-hmm.

Ed Pooley: 19:52

The other way I like to use it is preemptively as well. So rather than just using at the end of a, of a consultation, use at the start of a consultation, my particular area of interest is medically unexplained symptoms, often quite complex mental health issues. What I tend to do preemptively is text people before the appointment and say, we've got 10 minutes today. I understand there may be a few things you'd like to talk about. Can you just send me a bulleted list so that I've got something to refer to and I can organize my thoughts before you come in and if they respond to that, again, I've recorded the history in the notes or at least some of it, so that's saved me time. I know their list ahead of time and, and we all have those patients where our heart just slightly sinks a little bit and I dunno if you've ever found this, but sometimes. I'm so distracted by the sensation of my heart sinking that when they come in and they talk about just wanting something really simple, I, I almost dunno what to do with the sense of , sense of relief. And sometimes if I send off the text message beforehand and they say something like, oh, I, I just wanted to check that my prescription was ready, or I just wanted to check for my sick note to be renewed. Sometimes I'll just send the text back and say, actually, you don't need to come in today. We'll sort it out the phone, done. You know, that saved you A1 minute appointment, or you've got the list upfront and you can do something with it. And it, I think it's about using technology as a way of building a relationship rather than creating barrier to that relationship.

Munir Adam: 21:22

So, so how does that work in practice? I'm just thinking you wouldn't probably want to do that with all the patients. Do you have a selected list of patients that you might wanna use the preempt approach.

Ed Pooley: 21:31

I certainly do it with the ones where I know there's going to be a list, um, or where they're complicated or where I haven't seen them for a while, but I know that from past experience. It's the person that, it's the, when you open up the notes and there's some comment in the front page that says Needs double appointment, or something like that,

Munir Adam: 21:49

right.

Ed Pooley: 21:50

that some other commissioners put in, or there's, it's, it's an offer. They don't have to respond to it. They, they still get the same thing that they got beforehand, but it can really help build the relationship.

Munir Adam: 22:01

And you know what? If you do that, you're giving an opportunity to the patient to present their 10 different problems in written form, and then even if you don't address all of them well, can't possibly address all of them in one appointment, they've at least had a chance to relay all of that to you, which otherwise when they walk in, they're going to leave thinking, well, I never even got a chance to mention six of my problems, and what if one of them's gonna kill me tomorrow? So yeah, incredible. Going back to text messages, another thing that I found quite helpful is being able to use the templates where a lot of it's written down and uh, I know we do that for E referrals and things like that, and general cholesterol related advice and so on. Do you believe that text messaging is underused?

Ed Pooley: 22:42

I think it is. I think we're very used to using it to arrange appointments and do a lot of the transactional stuff that we do in healthcare. So we use it to. You know, tell people when their appointments are. We use it to tell people when systems at the surgery are down or not working, but we very rarely use it or generally speaking, to, to build the relationship or to, um, or to give people something that they can take away. So for example, there there is this concept of what we call tokenization. And that's where you are doing something actively or you are giving someone a token to end the consultation with. Um, and very often our traditional tokens have been a prescription or they've been an investigation request or they've been a follow up appointment. What I find is that by setting up that text message, that's often enough of a token to allow the patient to recognize that the consultation has ended and to leave without feeling they need a different token, let's say, like a prescription or, you know, something else that, that maybe may not have needed.

Munir Adam: 23:51

I have been guilty of that so many times And you know something, when we started to move to electronic prescribing, I felt I'd lost something because I didn't have something green to hand the patient as they left and they just say, you know, what's your pharmacy? And uh, and it goes there and then they're still sitting down. Whereas the green prescription was an opportunity to usher them to stand up almost. But actually, why should it have to be that way? And what they probably want more is to know that you're going to be following through with.

Ed Pooley: 24:20

Yes. I think patients have a need. Like we all do, just because we're human to, to recognize that we've been heard and to recognize that someone is doing what they need to do as part of their role to help us with the problem that we have.. And I think that that by doing these little things, you actually save yourself an awful lot of time. It feels like it's more time, but actually I have little statements that I just cut and paste from a Word document into the Accurx. I have some preset responses that work very well, or I'll actually type it out in front of the patients. They know what I'm doing, so they know what to expect.

Munir Adam: 24:57

Yeah, so it's convenient and it's documented automatically. Let's just stick on this area of within the consultation for a few more minutes then, and do you have any other top tips you can get from within the consultation itself?

Ed Pooley: 25:11

So I, I guess my sort of way of approaching time management starts from the moment they walk in the door. So reception will say, this doesn't happen in my current practice, but it's happened at previous practice I work in, where I'll get the reception team to say things like, your 10 minute appointment with Dr. Pooley is, is gonna start. Thank you for turning up early again. That's reinforced good behavior if you like. Um, Pop your jacket off and take a seat, and Dr. Will call you through shortly. So already you've got them to take the top two layers off. If they're already wearing coats that take you a minute and a half to know what to do within the consultation, then I'll call them in again. They've had their, they've had the fact that it's 10 minutes or however long reinforced I get them into the consultation and we begin the consultation. Things that save me time when I consult are not having a visible blood pressure cuff, not having a visible weighing scale, so I won't have them visible unless I need to do those things. Because often if people see them, they'll enter into a sort of a, oh, well I'm here. Can I just check my weight?

Munir Adam: 26:17

Oh, yeah, yeah, yeah. It's frustrating, isn't it?

Ed Pooley: 26:20

It can be because it's, it's using up time that you didn't really budget for where maybe there's a reading that you don't need.

Munir Adam: 26:29

Yeah. Yeah, yeah. And they get on and then it goes error, and then they get off, and then they get on again and it's still error, and they get off.

Ed Pooley: 26:35

and they take their shoes off and there's all sorts of, whereas, if you avoid those temptations and you remove them, you, you can speed things up a little bit. One thing that I quite like and what I call functional questions, so I think every trainee that has ever met me knows that I will never

ask is: 26:50

Are you short of breath? Which again is a really common consultation question, but what we really are asking that question for is to determine how worried should I be about your breathlessness? Are you at the anaphylactic acute asthma end of the spectrum, or are you at therial stuffy nose end of the spectrum. And the problem is that patients don't understand that They, they will say, oh, it's awful, where it's terrible and you see them walking around, you think, well, it doesn't look terrible to me. Whereas if you ask. What does your breathing stop you from doing? You then you can then miss out lots of qualification or clarifying questions because if a patient says nothing versus, I can't get outta my chair because I'm breathless, we know that we can already start directing the consultation. So I tend to like to ask functional questions cause I feel they've got a bigger yield.

Munir Adam: 27:44

Right.

Ed Pooley: 27:45

Um, so that's one way I get around that. Often, trainees will struggle with things like, how do I keep the patient on topic?

Munir Adam: 27:55

That's a, yeah, that's a big one.

Ed Pooley: 27:57

My two best ways of doing that are to use a, use very neutral expressions. Like I'm aware of the time

Munir Adam: 28:05

Okay.

Ed Pooley: 28:05

to which a patient may then go, oh, uh oh. Yes, okay. Of

Munir Adam: 28:08

Oh, just like that. I'm aware of the time.

Ed Pooley: 28:11

Yeah, I'm aware of the time. Let's focus on X, Y, and Z, which is a very kind, very neutral way of interrupting someone. You know, if you have to be a bit more belligerent, you can say, I'm gonna have to stop you there. We need to move on to looking at things so I can make sure that I'm keeping you safe. Again, you frame that as something that is for the patient's benefit. They aren't gonna disagree with you. They're not gonna say, actually, no, I'm gonna talk and and you are not going to keep me safe because that's, that's

Munir Adam: 28:40

Well, no. No, because ultimately that's what they want, isn't it? To be kept safe. To be. Wow. And you've just explained to them that , if that's what you want, then we've gotta move this consultation in a certain direction.

Ed Pooley: 28:52

Yeah. Do you remember when you did, um, paeds training? Well, there's, there's always this, this mindset of opportunistic examination isn't there. You've got a wringly child.. My flip side of that, particularly with more elderly patients, is opportunistic history taking. So when they come in, they'll have rehearsed a storyline and a way of understanding their symptoms. And they might start off by saying, oh, I met my friend Mabel at the bus stop the other day and she was telling me about her leg. And oh, she's having a lot of trouble with that. And my leg started playing up the same. If you try and wrestle away that that narrative and make it very much more doctor centered, and you start talking about, tell me about your knee pain. When did it first start? How is it, what's it doing to your daily life? You tend to find that the patient is. Is returning to their own narrative, which is just using up time. If you ask them questions that are congruent with their narrative. So for example, oh, what was the problem with Mabel? Did you think that was the, the problem with your knee? Tell me about your knee. What, what have you noticed? What was different with, you know, did you find that when you were standing at the bus stop you, you're getting any pain on standing? All of these things that are very congruent with the story makes the consultation flow better, it tends to get you where you need to be, and it's being respectful of what the patient has pieced together as their understanding of their symptoms and, and the worries and the unvoiced concerns that they have. And you've tried to bring all that together and, if you get the history out of that, that will look like a really slick consultation. And then you can say, well, there, there are a few things I just need to check with you. Thank you for giving me the background. I just need to focus on this, this, and this, and then you're done.

Munir Adam: 30:37

Uh, yeah, I know this is it, isn't it that we very quickly wanna go into our doctor centered or clinician centred perhaps I should now say, way of asking questions and just trying to focus on the bits that we want. And something about, is it just a case of just being quiet and letting them talk and then facilitating? But that's interesting because one might go down and ask a question like, oh, I'm just gonna move away from, and ask you a few specific questions to help you. But even though I'm phrasing it nicely, I'm actually still just moving away from their agenda. And what you are saying, if I understand you correctly, is just facilitate their side of the story. Let's hear it from them, clarify it from the perspective of what their experience is like, rather than just taking over the whole consultation. And then you may get a lot of the story out and you may not have that many questions you need to ask after that.

Ed Pooley: 31:25

It's kind of like the, a modified golden minute. You're sort of easing the patient along their story and you're having more of a conversation with them as they go, but it, you're not asking questions that are so jarring that it will derail the story and then they'll have to start again.

Munir Adam: 31:40

Hmm. Okay. I was just thinking back to some patients who, I don't know, minutes seems like not enough for them. Do you come across those as well and they want to carry on 2, 3, 4, 5 minutes? How do you deal with that?

Ed Pooley: 31:55

Normally I'm fairly upfront and I'll say something along the lines of, do you know, it sounds like there's an awful lot to, to pick apart here. I can tell from, your description of everything going on. There's a really big backstory to this and what I'm conscious of is that I need to get out some really clear points from you in order to keep you safe and to know exactly what are we're gonna do next. Because, you know, we've only got 10 minutes today. Uh, and that's not your fault and it's not my fault either, but we just need to get out the main points from this. Will you just bear with me while I ask you a couple of quick fire questions?

Munir Adam: 32:32

A couple of times here in the last few minutes, you've mentioned this concept of time and bringing this out and sharing that with the patient, and this is something that I feel very comfortable doing now. But certainly for the first five years or so after qualifying, I would've seen that as being almost unprofessional. I mean, the thing is, you go to your bank manager or an accountant or you know, anybody out there they don't normally say to you, well, I've only got 10 minutes, or I've only got 15 minutes. It almost sounds like they're trying to get rid of you from the word go, but you're now explaining it in a way where it isn't actually mentioning time itself, that's the problem. It's the how you do it.

Ed Pooley: 33:07

Yeah, it, it is the, how you do it really because you know, your bank manager and your accountant and your lawyer are all rewarded in a different way and they all have different pressures. The reason, the reason they don't talk about the time is they are ultimately probably wanting you to purchase something. Whereas for me, it's about creating a mutually respectful relationship. There's an analogy I give in the front of the book, which is, if you're in a traffic jam and there's a car in front of you, and the driver of that car is just letting everyone through. They're feeling really good about themselves and they're getting all the reward because they're just looking at the people in front that they're letting through. What they're not considering at all is the massive queue of people that's also formed behind them.

Munir Adam: 33:49

Oh yeah.

Ed Pooley: 33:50

To lose your focus with the stuff you can see in front of you and forget about the people who are also waiting for something. You know, you, you can, and we do take our time and we use extra time if we need to, but we've also gotta be mindful of the fact that if that then makes us rush through the next three consultations, one of whom may be reluctant to tell us about rectal bleeding or weight loss because they can see that we're harassed and poor actually, that we may then come a cropper. And it's about having, you know, there is that, there is that sense of , justice as Beacham and Childress would put it, that you have to give an equal amount or a proportionate amount of your time for the other people as well. And if you used up all your time on one person who is just using your time because you are giving it freely and not considering the cost of that, then you may be doing yourselves and other patients a disservice.

Munir Adam: 34:44

Gosh. Yeah, because when we're running late and when we're spending a lot of time, or if we, the way we feel, it certainly is where a patient is making us spend a lot of time. I think that we often go into a almost selfishness mode and start to think about how this is making us fall behind, but actually worse than that, we're making others wait longer. And the result of that could be that we might miss something serious because we look rushed and so on. And perhaps we need to be seeing, spending too long with one patient as being an unfair, rather than just being extra generous. Mm.

Ed Pooley: 35:18

Yes, that, that would be my, that would be my thinking on it.

Munir Adam: 35:22

Is there anything else that's coming to mind about consultation. Ed Pooley: So one, one thing that I particularly when we were doing a lot of phone calls, was, Um, there was a lot of dis dissatisfaction among medics that they were ringing up and people weren't answering or people were in the car and it wasn't a convenient time. And actually they were just using loads of time on the administration of making calls and calling back. And so what I kind of proposed was that if you tell people that you're gonna call within an hour window, let's say when the first patient books at eight 30, their hour window starts at eight 30, the next patient starts at 8 32, but then goes on to nine 30. So they all have a rough window in which the clinician will call them, and so they're able to dedicate that time to just keep it clear in much the same way that we'd wait for an Amazon delivery if we knew it was a really important package or we had to sign for it. And that way you save yourself so much time on the administration of medicine, the calling back, the the missed calls, the, can you call me later, doctor, because I'm currently on the loo kind of things.

, Munir Adam: 36:29

I think the delivery example that you give us a really good example because I think we can all relate to it in these days. You know, lots and lots of things are ordered online now, whereas historically we might have gone and purchased things in person and it is frustrating when you get an email that says, this could be delivered anywhere between 8:00 AM

and 6: 36:43

30 PM What am I supposed to do? Just sit at home and wait for you to come. And actually, it's only recently that as a patient, well as a relative of a patient, The GP surgery said, oh, well a doctor's gonna call you somewhere between eight and 1230. And I thought, what? That's not reasonable.

Ed Pooley: 37:02

Really hard, isn't it? Cause you know, we're all under pressure. We are all firefighting, we are all picking up the pieces of a health system that is struggling. There are two ways that you can think about that. You can think about, well, how can I make my bit of the healthcare system as efficient as possible and in a way that gets patients what they need and also gets me what I need because I, I don't need to feel angry and stressed at the end of every day that people aren't sick enough to warrant my time or all of these things that we start thinking about when we get angry and we're, we're burnt out. And actually flipping it on its head and thinking if I was a person ringing a surgery, would I be able to keep my entire day free As for a non-life threatening condition? Probably

Munir Adam: 37:47

No.

Ed Pooley: 37:47

And actually that's just amount of waste that that creates an a system with people missing an appointment, calling back. You know, that's using the receptionist time, that's using your admin time, that's generating a complaint, possibly, you know, all of these things.

Munir Adam: 38:00

Hm.

Ed Pooley: 38:01

And actually we don't have to be belligerent about we, we can find a different way and see if it works with our patient population, and if it doesn't, we try another technique and we work that and see if that works..

Munir Adam: 38:14

Do you know what's so amazing? I was reflecting on the points that you've been discussing and actually, I think I'm right in concluding that everything you've said so far. It is, yes, the primary focus of the discussion is about us saving time, but actually it's things that patients will appreciate. So this is not about saving time at the expense of patient care, but actually quite the opposite. Saving time and it being what patients actually want from us. You know, you mentioned a lot of things like about how a text message may save us time, but actually it's what a patient would prefer. And having a system where you just mentioned it now about having a telephone consultation at a narrower range that you're gonna call them back is both better for you because you're less likely to end up having an engaged tone on the other side. And it's better for patients because that's what people prefer to have a more specified time. So actually, this is a really important message. Some of us may know it. Some of us may genuinely believe that saving time means that you're gonna be providing lower quality, but even those of us who don't believe that we often, especially if we're running late, we end up falling down that trap where, oh my God, I'm gonna rush. I've gotta do things more quickly. And it doesn't matter if patient carries slightly less than I would normally do, um, moving away from the consultation. Are there other aspects that frontline conditions should be thinking about in their day-to-day work or day-to-day life? Working in general practice to get better organized.

Ed Pooley: 39:38

Yes, I think there's various things that we do that can all be done in slightly different ways. Um, so I'm a big fan of any time that you save shouldn't be just plowed back into patient care. There's a very big risk of creating time for ourselves. Let's say we manage to create a 20 minute slot in our day. There's then almost a risk that we fill it as quickly as possible with something else. And actually what we need to do is to reclaim that time for ourselves to think about how are we doing? How are we able to, you know, how do we have enough time out here? Do we have some capacity to reflect and, reduce that cognitive overhead of constant decision making and decision fatigue so that actually we see the rewards of our time management skills, not the patients or the system because the patients or the system probably won't thank you for saving 20 minutes off your day.

Munir Adam: 40:39

Hmm.

Ed Pooley: 40:40

Whereas actually your family might, or you might. And so I'm a big fan of that. So if you if you do save time, work out a way for reclaiming some of that for yourself. Second thing would be we often get trapped into what I call task- itis. In medicine, we'll often send ourselves tasks to do a referral or reception will send a task to call a patient whenever you are free...

Munir Adam: 41:05

That varies a lot, doesn't it, from one practice to another? Some practices have got a habit of squeezing in, just squeezing in extra patient; squeezing in extra work, squeezing in extra queries from reception, and then you go down that spiral of just getting more and more late.

Ed Pooley: 41:20

Absolutely. It's, it's really, really difficult and, if it requires a block of work, then that patient gets booked in for a phone call or that get patient gets booked in for a face-to-face. It's not, can you call patient at some point in the next week? If we take the example for, for instance, of, of sending yourself a task to write a referral, often they'll just sit there and they'll build up and they'll build up and they'll build up. And what is a more efficient way of doing it is to have an audit set up so that you, you search for a code and you can pick whatever code you want on the system that you use. And it's also a safer way because then your secretarial team or your admin team can check whether something has been done because you've added a code. Um, things like emails, for example. The number of emails that we get that we really don't need to see is huge,

Munir Adam: 42:09

Don't you get frustrated when some people just do reply all for everything, don't they?

Ed Pooley: 42:14

Absolutely. And, what tends to happen is if we just get loads of emails that don't mean anything to us. We tend to then ignore the ones that do because they just become part of this email pile that we ignore. It doesn't seem relevant, so psychologically we, we see the less urgent things as less urgent.

Munir Adam: 42:34

Yeah. Oh gosh. Email could end up becoming a, just a whole full discussion on its own , right? Couldn't it?

Ed Pooley: 42:41

Absolutely. Email is one of those things that's almost too easy to

Munir Adam: 42:46

And, and you know what? Too easy to lose that precious time that you mentioned a little while ago because, as you were describing that, I was thinking, oh no, I don't waste those 20 minutes. I end up looking at my email. But actually I then heard what you said next. It's actually, this is time not to be using your brain in that way, but actually using that as an opportunity to relax.

Ed Pooley: 43:06

We often compartmentalize things in our heads, so it's often not just email. So we'll often browse email throughout the day and then we'll get sucked into the notification on Facebook about someone who's made the browser. And, we've all got these dopamine reward pathways, and all of these systems are set up to trigger them. They want your attention.

Munir Adam: 43:25

Don't they just, yeah.

Ed Pooley: 43:26

You know, every Facebook notification is pinging, is just firing that reward system. Your system doesn't differentiate between a Facebook notification and, you know, cocaine, for example. It still gets the same reward pathway that's hit...

Munir Adam: 43:41

gosh

Ed Pooley: 43:42

...reinforces it.

Munir Adam: 43:44

if, if I ever didn't feel bad enough about Facebook, you've done it now. It's like cocaine. Gosh, no wonder we're exhausted at the end of the day. Certainly many people are gonna say most of the..., do I, I don't get five minutes free in a day, but actually we do sometimes; we just fill it with things, don't we?

Ed Pooley: 44:02

We do and it, and it switches off that, that logical part, that time management part of our brain. And so before we know it, 20 minutes, 30 minutes have gone and we wish that we could get them back.

Munir Adam: 44:13

Gosh, ed, this is really fascinating. And they're not rocket science, the things that you're saying. You mention it, and actually I'm thinking to myself, you know, I can implement this. Because we're busy, we don't think about, or we don't focus on our time. What most of us do is we moan, don't we? We moan about the time. We moan about the work, but you took it head on. What I wanna do is ask you that maybe just to round down the discussion, what drove you to do that?

Ed Pooley: 44:41

So before I was a medic, I was a researcher.

Munir Adam: 44:44

Okay.

Ed Pooley: 44:45

So I, I did a PhD in psychiatry and behavioral genetics, so I like seeing how systems work. And I also run my own business as a web developer. So I, I like the logic of things like computer programming, understanding systems, and, and I like lots of different areas. And one of the things that I noticed around about 2020 was that, there's lots and lots of information out there about how we can do things more effectively, but they're very often targeted at their own specific audiences. So for example, there's hundreds of time management books, and they're all specifically targeted at managers who have a different mindset and a different way of looking at the world than doctors do. You know, doctors, for example, are fairly altruistic. Um, but surely if we spend less time with patients, that means we're doing less good a job. And all of these sort of hangups and, and thoughts that we have, and actually what people need is someone to translate that knowledge that already exists into a format that's more acceptable for them. So I set up this group on Facebook called Difficult Conversations. And it, it's basically designed to look at areas of expertise and see how we can use those and apply them to medicine. So I spend a lot of time talking about communication theory, psychotherapy principles, psychology, sales.

Munir Adam: 46:10

What we all need to do is join that Facebook group and of course we'll share a link to that as well and we'll pick up tips from there as we go along. And you never know, isn't it? You look at something on Facebook and you think, yeah, maybe I'll use that one day, and then you find yourself using it a couple of days later. And yes, I know where I got that from. I got it from Ed Pooley's Facebook group. I've got things to implement and I'm sure others have as well. Thanks for joining and that's fantastic.

Ed Pooley: 46:36

Thank you. Thank you for inviting me.

Munir Adam: 46:42

And so it's over to you now. What will you do differently from what you've heard today? We hope that there have been at least a few take home points for you. What would be better still is to actually record that. Why not send us your comments? Yeah, that's right. If you're listening on an Apple podcast, you can rate us and leave comments usually by scrolling down the page and some other platforms allow you to do that as well. But if not, you can use the links in the show notes as well. And not only will that reinforce your learning, but it will also help us keep this show free from private sponsors and ads. And why keep it to yourself? Do share the episode link with your friends and contacts and on social media. Well, that's it for today, but we'll be continuing our journey of time management in consultations and in primary care in our main episodes for the next few months. In next month's main episode, I'll be speaking with Professor Roger Neighbour, former president of the Royal College of a General Practitioners. Before that, we'll have an interim mini episode as well on something totally different. Do join us then, but for now, keep well and keep safe.