Time managementBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7137.2 (Published 04 April 1998) Cite this as: BMJ 1998;316:S2-7137
If today is tomorrow's new yesterday, where did it go? Carl Gray on using or losing the most precious resource
“But at my back I alwaies hear Times winged Charriot hurrying near” wrote the 17th century poet Andrew Marvell.(1) His words are still relevant today, and time is central to medicine. From our Apgar scores at birth to the widening intervals of Cheyne-Stokes respiration, medical episodes are measured chronologically. Patients must wait in the waiting room: “Dr Godot will see you now.” Taking a patient's history turns on time: “When did it start?” “How often are the contractions coming?” “Why didn't you report this sinister sign sooner?”
The human body works chronobiologically, and cardiac arrests, histopathology reports, and triennial reviews have their own response times. But the practice of medicine is frustrated by time wasting. Medical employment is contracted by notional time. Seniors have half days, and trainees have duty hours, but never enough to do all the work. Acute punctualist or chronic time-waster, the use of time in a medical career determines its success. Finding a moment to peruse Career Focus is a healthy sign, but are you wasting most of the billion seconds available in your 30 year career - Oops! There goes another one, two, three…
Many doctors are failing in their use of time: white rabbits in white coats looking at pocket watches and scurrying along corridors muttering, “Oh my ears and whiskers, how late it's getting.” Almost every problem in medical practice relates to the efficient use of time. Clinics, theatre lists, and surgeries often overrun, diagnostic tests are reported late or not at all, and administration is in chronic frame shift to the right. Late doctors waste the time and money of all those next on their list: patients, other professionals and students, but mostly themselves.
Few deliberately delay: time failure is more fundamental than mere endemic lateness. The typical picture is doing more and more, in a rush and always late. Every part of the NHS is facing increasing workload, which is producing the illusion of increased unit efficiency, especially in diagnostic departments. But the hidden costs lie in eventual wear and tear of the workers, public perception of a slowing service, and the waste of effort which could be better spent. In the headlong rush we deal with the urgent ahead of the important, with tactics rather than strategy, and starting rather than completing. Gentlemen finish last, but when will that ever be?
At the human scale - large bodies moving through space - physics is Newtonian and time is a linear parameter. If you are sitting comfortably, gravitation can be taken for granted and relativity of space and time ignored (unless you inadvertently approach the speed of light; unlikely in outpatients unless using the laser). Despite our molecules visiting quantum futures, practical tasks take predictable spells of Greenwich Mean Time. “Am in Market Harborough, where ought I to be?” Unlike G K Chesterton's telegram, your diary and your Rugby-controlled radio clock should put you in the right place and time.
Although musicians can pluck an accurate andante out of the air with their mental metronome, perception of time is fluid. If clocks are set experimentally to run at different rates, hapless human guinea pigs do not notice: they alter their activity to match the time cues. Famously, people isolated in caves tend to adopt different diurnal cycles, often longer than the Earth's 24 hours. Even in a cave, time drags with toothache but flees with a kiss. Those childhood summer afternoons, listening to the crack of leather on boy, lasted for ever because the content was so low. But time flies when you are busy.
The psychologist of everyday life, Csikszentmihalyi, has defined the loss of perception of time when concentrating as “flow.”(2) Flow activities demand a close match between challenges and skills and represent the pinnacle of experience. Examples include rock climbing, the performing arts, and complex surgery. The same experience underlies musical rapture, religious or sexual ecstasy, and athletes “being in the zone.” A person going with the flow is utterly engrossed, does not watch the clock, and afterwards feels the glow of happiness.
Control of mental time by training is feasible. The rhythm of consciousness allows flexibil- ity: perception of time is inversely proportional to the speed of thought. Train yourself in rapid reading, recall, and decision making and time will spread out, allowing you to get more done. If you are often bored, you have insufficient mental processing going on, probably because of insufficient input.
Time management was invented by the railways - as was the first unified “railway” time - and in its heyday the Flying Scotsman was timetabled to take exactly seven hours to travel the 393 miles from Kings Cross to Edinburgh.(3) Railwaymen had predictable recovery margins for each stage of the trip and allowed about 15% “making-up time” to accommodate any problems. So should you. Delays are to be expected in all journeys these days, especially by car and even in walking across the hospital: “Good morning, Chaplain…” You might shave some time off each procedure, but practical work is the least amenable to trimming.
Just say “No”
Important things first
Right first time
Stop when it's good enough
Think, read, and decide faster
Master information technology skills yourself
Expect the unexpected
Communicate with brevity
Strategy saves time in the long run
Classic time management is well worked out, and good texts are available.(4) I will save your time by summarising their content. Recognise your own biological clock and use your most effective times for important tasks. Use time only on things worth doing and stop when they are good enough. Stop wasting time, sort out conflicts in your timetable, and communicate using the briefest methods. Efficiency tricks are listed in the box above and time wasters are shown in the box below. Despite the common sense of all these techniques, many would find themselves wanting in a critical review of last week's timetable. The crux of the problem is the personal recognition that you can do better with the time you already have passing by.
Schoolchildren traditionally worked out the lifetime total of each daily activity: 30 years asleep, five years eating, and so on. Recent adult translations include two years sitting in traffic jams, 11 years watching television, and up to five years in sexual congress (though, happily, not all at once). Professional totals might well include long years looking at the ceiling in meetings, answering the telephone, searching for lost paperwork, and getting the fax machine to work.
Unpunctuality in self and others
Meetings - too many, too long, too little content
Paperwork - filing, searching, opening mail
Underestimating time required
Interruptions - calls and callers
The inevitable phases of a medical career - student, trainee, practice, retirement - are matched by steady increases in the criticality of time. Medical students have quality, coffee, and bed times growing on trees. Even after attending all classes and sleeping three hours a night with different partners, abundant hours are left for parties. The trainee doctor has more duties timetabled, with increasing responsibilities and the dreaded on call. The career grade doctor has to allocate waking time between the wide range of urgent duties and important responsibilities as well as dogged attendance and stuff to do. The retiree begins to treasure the dwindling future, having wasted too much of the past: as Herrick wrote, “Gather ye rosebuds while ye may, Old Time is still a flying.”
Wise doctors will find a minute to think again. The new professional supervisory era in the royal colleges and the GMC will not excuse doctors who fail through overwork. This should concentrate minds wonderfully. Time- tables must be reviewed critically: not only by reassessing the volume of work and allocation of aeons to each practical task, but also recognising the importance of catch-up time for unforeseen circumstances, and finding some milliseconds of thinking and enjoyment time. Time paradoxes abound. Going in later saves time by allowing extra sleep, avoids the rush hour and useless start up activities, and delivers a livelier person on arrival. Staying late seemingly gets more done, but the work is of poorer quality and has costs to be redeemed the next day. Working at home can be more productive and creative. Much of what we do is unnecessary. Give a job to a busy person, and it happens. Longer holidays facilitate strategic thinking, which saves time overall. Enough sleep and positive leisure prolong active life. Early retirement from one job enables continued employment in a wider portfolio. So start by stopping. Just say “No.” Take the day off, declare that time is standing still for quantum reasons, and reconsider your place in the astronomical epoch. You are paid to deliver a service and fulfill a role; stop clock watching and relax into flexible longueurs. Read up on time management - by speed reading - and apply some techniques to your job. They will work immediately. Use the brain's ability to extend time; consign all useless activities into a parallel universe and reorganise a black hole (your office).
Three hundred and sixty years after Marvell, schoolchildren still hear annually the end of term reading from Ecclesiastes(5): “To every thing there is a season, and a time to every purpose under the heaven;” times to be born, die, heal, plant and pluck, love and hate, and, most importantly, “A time to get, and a time to lose; a time to keep and a time to cast away.” With this authority, take your clock outside and jump up and down on it while shouting, “Clockwork universe or go with the flow?” (This should be worth six weeks' leave with medication.) Gosh, is that the time? Quickly! Give it to me straight, Doctor. How long have you got?
I thank Keith Anderson for factual information.