TIME MANAGEMENT IN THE DOCTOR- PATIENT CONSULTATION

Introduction

Time management in the consultation is a common problem voiced by doctors whatever stage their training and experience; specialists as well as GPs all have  problems with time;

they describe the problem in a number of ways:

·      they can’t end the consultation

·      always running behind time

·      never finish on time

·      can’t get the patient out of the door

·      can’t stop certain patients talking

·      too many problems to deal with

Doctors also voice the concern that if they listen to patients, or attempt to understand their ideas and concerns, surely the consultation will take longer!

So,

·      what are the problems?

·      how do they arise?

·      are there solutions?

·      what can help?

A suggested structure and some possible exercises for a teaching session on time management

objectives:

·      to explore the problems of time in the consultation

·      to discover what influences time management in the consultation, and where problems originate

·      to look at how the doctor and patient feel about time and the lack of it in the medical interview

·      to work out strategies for improving time management

Ways of exploring the problem of time in the consultation 

1.  Round or pairs exercise

how does being short of time/running late in the consultation/surgery/outpatients make you feel ?

flip chart the responses

similarly how does being on time / having enough time I the consultation make you feel?

Flip chart the responses

Discuss

  2.  Brainstorm or paired listening exercise

·      what are the difficulties for you concerning time in the consultation?

Write on the flip chart all the ideas which come up from the group

Discuss

do any patterns emerge?

Further question to focus group members

·      what gets in the way of our consultations running to time?

·      what stops us consulting to time

Group what comes up under the following headings:

·      things outside the doctor which have to do with the structure of the practice/outpatients;

            booking times

            interruptions

            emergencies

            not having the notes/not being prepared before the patient comes in

·      things more to do with the individual doctor which are internal

            tiredness

            depression

            anxiety about family

·      things to do with the patient

            the patient is late

            the patient never stops talking   

the patient with a complicated problem

            the depressed or psychotic patient

            not understanding why the patient has come

            the patient with a list of problems

giving information not on target

not finding out the patient’s framework

Discuss

4.  Exercise: round/trios

What is it we are trying to achieve overall with our patients / for ourselves overall in a consultation / ward round/ outpatients?

What is it about time that stops us/helps us to achieve these objectives?

 5. Exercise    What could we do to improve things?

What would the group like to tackle first?

Pairs 3 minutes each way

Take one of the above in turn and work out the strategies which might help.

These could be quite practical solutions; eg consulting at 10 minute rather than 7 minutes; being properly prepared before the patient comes into the room; stopping interruptions, telephone consultations;

or

recognising that you are tired and not trying to tackle all the problems the patient has come with; accepting that you are happier consulting slower than your partners or colleagues,

or

working out the structure and skills which help with time management in general practice

listening

discovering why the patient has come

discovering what their most important problem is today that they want to tackle

screening, agenda setting

checking and clarifying

discovering the patient’s framework and discovering it before you proceed to explanation and planning

sequencing and summarising

negotiating       

 6.   how individual doctors wish to work

The group might like to tease out what they are comfortable with; how they wish to consult; what sort of doctor they are temperamentally; how they wish to work with patients. 

7.  Discuss whether patient-centred consultations are longer

Look at the evidence

Stewart (1985) looked at 133 interviews in primary care and compared their “patient-centredness” score with the length of the consultation. Low scores for patient centredness produced interviews of on average 7.8 minutes, intermediate scores 10.9 minutes and high scores 8.5 minutes. Her conclusion was that doctors who have mastered the patient-centred approach took little extra time than doctors not employing these techniques.  

Roter et al (1995) also found no increase in the length of interviews in primary care following training in the skills of “problem-defining and emotion-handling”.

Levinson and Roter (1995) showed that primary care physicians with more positive attitudes to psychosocial aspects of patient care used more appropriate communication skills and as a consequence their patients had more psycho-social discussions and appeared more involved as partners in their own care. Yet these same physicians did not have longer interviews than their colleagues with less positive attitudes.

 Look at a video using ALOBA where a learner has a particular problem with time management 

Then summarise what the group has learned about time management and relate to the framework and the skills of the C/C model

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